Today’s post was inspired by a client of mine who came in for their training session recently but confessed that their knee wasn’t feeling so great.
Given there were a bunch of squats on the agenda that day this wasn’t ideal news to hear. However, rather than sound the alarm and nix squatting altogether I wanted to see if I could alleviate their symptom(s) with a simple intervention.
But this “trick” I’m about to show you has worked wonders – as in instant relief – for various clients of mine who have complained of cranky knees.
A few brief notes:
1. I receive no affiliate income or kick-back (other than unlimited hugs) from ACUMobility for recommending their product(s).
2. It’s unfortunate many health/fitness professionals fail to look BELOW the knee with regards to knee health and function. The knee joint is pretty stupid and is often at the mercy of either the hip or ankle. By all means I’d be remiss not to encourage practitioners (which isn’t my role as a lowly strength coach) to assess the knee to see if there’s any nefarious nonsense happening there.
However, in my own experience, when trying to dig a bit deeper as to WHY someone’s knee may be bothering them (outside of the actual knee itself), the lower leg gets the shaft.
3. One component is looking to see if the individual can actually rotate their tibia (lower leg bone) in relation to the femur. Many patellar tracking issues, for example, can be attributed to a lack of tibial rotation…
If I were to make a list of what ACTUALLY affects patellar tracking the most it would likely look like this:
1. Lack of ability to rotate tibia.
2. ITB/adductor “tightness.”
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5. Lower leg (calf) griminess (<– technical term). See below.
18. Brexit.
19. Kitty cuddles.
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277. Belly button lint.
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412. Weak VMO
The tibial rotation thing is something I do want to address and is something I may write about in more detail soon. In the meantime, if you just can’t wait that long, Dean Somerset and I JUST ANNOUNCED we’ll be in Athens, Greece this October to reunite after 3+ years (and a pandemic) to put on our popular Complete Shoulder & Hip Blueprint Workshop – where we discuss this topic in more detail (and much, much more).
(Side Note: If traveling to Athens isn’t in the cards you can always follow along at home with our digital course HERE).
But First…
A caveat.
With regards to “general” knee pain I’ll typically start with a technique audit and then make some modifications in terms of volume/load and which variation of those exercises someone performs.
Sometimes the fix is some coaching to help clean up someone’s form.
Likewise, sometimes the fix is modifying the lift ever so slightly – reducing ROM, widening their stance, changing foot position – to make the lift (in this case, barbell squat) more tolerable.
I’ll always start there because it’s the lowest hanging fruit at my disposal and it ensures the client will still elicit a training effect. That and I’m a big fan of avoiding making my clients/athletes feel like a patient.
After that I’ll attempt to address tissue quality…particularly in the calves (an often neglected area).
Ouch (I mean, Great)
The gastronemius (or gastroc for those of us who are lazy) is a bi-articular muscle that crosses both the ankle AND knee joint.
It’s a nasty area that, for lack of a better term can “get nasty as fuck.”
I often find if I have someone work on their tissue quality in this area that they’ll find immediate relief in their knee(s) because it helps “unglue” their tibia to rotate more during the squat motion.
It’s not fun, but it works:
Try this the next time your knees toss you some attitude.
The prevailing thought, it seems, is that admitting ignorance is a sign of weakness or that you’ll somehow lose credibility points for not knowing the answer to a client’s question…
…as if the fitness industry’s equivalent of Unella is stealthily lurking somewhere to shame walk you down a corridor for not memorizing every delicate step of the Kreb’s Cycle.
Listen, there are some things a personal trainer/coach likely should have a firm grasp on:
The muscles of the rotator cuff?…✅
How to program around low back or knee pain?…✅
How many calories in a gram of protein?…✅
Who Mel Siff is?…✅
But you can’t expect to know EVERYTHING about anything:
Where’s the Levator ani located?…🤷♂️
And, more importantly, what the hell is the Levator ani?…🤷♂️2
What are the benefits and pitfalls of concurrent periodization?…🤷♂️
What’s the atomic number of Adamantium?…🤷♂️
Maybe you knew the answer to all of the above, and if so, can we hang out? But if not, and on the off-chance someone in your life – whether it be a client, colleague, or your second cousin on your stepmother’s side – asked, and you didn’t know the answer, how would you handle it?
Rather than play hero, pretend to be an all-knowing smarty pants Spartan Jedi Wizard deadlifting demigod, and manufacture some false, pseudo-intellectual response…I’ve found it to be best practice to be honest with clients.
Simply put, to say…
“I don’t know.”
This bleeds of authenticity and I’ve found that, 100% of the time, clients appreciate and respect the honesty. Kind of like when you do someone a solid and let them know they’ve got something in their teeth.
I’ve never lost a client because I was unable to answer their question regarding the functions of the psoas muscle or, I don’t know, the efficacy of heart rate variability training in undertrained grizzly bears.
Namely because 1) I TOTALLY KNOW WHAT THE FUNCTIONS OF THE PSOAS ARE and 2) the latter is ridiculous.
But too, it just never happened.
If I don’t know the answer to a question or a client asks to dive deeper into something I have little expertise in, I’ll say “I don’t know,” followed by “but I know someone who does. I’ll ask them.”
This happened to me not long ago.
I had a client express interest in learning more about the Olympic lifts. Up until that point she and I had been working together for several months focusing on the basic barbell lifts – deadlift, squat, bench press, etc.
She was a stark newbie when she walked into CORE the first day but had made a ton of progress in a short amount of time. It wasn’t long before she started asking whether or not I’d be willing to add OLY lifts into her programming?
(cue crickets chirping on my end)
Full Disclosure: I don’t have a lot of experience performing – let alone teaching – the OLY lifts. I even wrote about why I don’t include OLY lifting in my programs HERE. TL/DR version: I’m more qualified to fly an Apache Helicopter than teach a passable barbell split jerk.
Without blinking an eye I connected her to a handful of coaches in the Boston area more equipped to help her out.
And it couldn’t have worked out more splendidly.
She sent me the most gracious email a few weeks later saying how much fun she was having and that she had “found her people.”
Some people reading may say something to the effect of “dude, Tony, you lost a client. That’s the opposite of what I want to happen to me.”
Touche.
In the literal sense I did lose a client.
However, what do you think is the likely outcome when she’s approached by one of her family members or friends or colleagues asking if she knows of any reputable trainers in the area?
She’s going to refer them to this guy that’s what’s going to happen.3
If There’s Two Things to Remember From This Post…
1. Your clients won’t care that you don’t know the answer to something. Saying “I don’t know” is the responsible response.
Followed by “but I will try my best to find the answer for you.”
2. Don’t think pointing your clients towards other fitness professionals (especially locally) is a poor business decision. In my experience every time I’ve done so has resulted in the same client referring more people to me. Once they understand you have their best interests in mind they’ll often reward you with unabashed loyalty.
3. Just to be clear: I don’t know shit about fuck when it comes to the Kreb’s Cycle.
Outside of majoring in “Humanities” during my first few years in college, and taking the obligatory Introduction to Philosophy class to fulfill my course requirements, I don’t consider myself much of a philosophical person.
I’m not one to sit around and contemplate the meaning of life, why we’re all here, or to argue about which came first: the CrossFitter or the comment from the CrossFitter that they do CrossFit?
I tend to leave those sort of things to people who are way smarter than myself and drive Priuses.
Start a conversation with me on Star Wars mythology or the writings of Kurt Vonnegut (or bring up the best Jason Bourne fight scenes) and you’ve got my attention.
So, yeah, I don’t consider myself a philosophical person per se. I put my socks on like everyone else. But something struck a chord and jostled my thought process recently as I was listening to a podcast.
And it was this one simple quote: “Discomfort builds growth.”
The easy analogy here – and most fitting – are the things we do in the weight room.
I don’t know about you, but I don’t go to the gym day in and day out because it tickles.
I do it because I want to feel strong, look strong, and have pecs that can deflect bullets.
However, how many times have we noticed someone do the same routine, with the same exercises, in the same order, with the same amount of weight, routinely, who look exactly the same and are just as strong as they were three years ago?
Hell, I’m sure everyone reading knows a friend, family member, colleague, arch nemesis who falls under this umbrella.
I’ve worked with countless people in my career as a personal trainer and strength coach.
98.5% of them “get it.”
Meaning, they know they have to put in the work in order to get the results they’re after. They don’t just expect muscles to magically appear or to walk underneath a rainbow and lose five dress sizes.
They have to EARN it.
They’ll do what they’re told – throw some barbells around, push the Prowler, swing some kettlebells, perform endless numbers of push-ups and chin-ups, tolerate Wu-Tang Wednesdays – and love to hate it.
It not so many words (and at the risk of being overly cliche)…
They’re Comfortable With Being UN-Comfortable
This isn’t to say one must train to the point of passing out or shitting their liver in order to reap any benefits. That’s a bit much.
Conversely, just because you “showed up” and made an appearance at the gym doesn’t really mean anything.
Why drive to the gym only to walk on the treadmill?
For many, they’re lucky if they elevate their heart rate during their “workout” any higher than if they just stayed home and watched an episode of The Last of Us.
Very generally speaking, those people who have physiques and fitness levels we most admire (and desire) are those who strive for, nay, ACCEPT discomfort.
It’s physiology.
The human body is a highly adaptive “machine.” The reason why many people never seem to make routine progress in the gym is because they continue to do the same things they ALWAYS do. Even worse, they continue to do things that they’re good at or that’s “easy.”
I don’t blame them – it’s human nature.
I know I’ll catch some flak for saying this, but a glaring example would be people who tend to gravitate towards “cardio.”
Performing dedicated (steady state) cardiovascular work is important and it does serve as an component to a well-rounded fitness program. But I do feel it’s often drastically OVER-emphasized because, well, it’s easy.
And we’ve established that people like easy.
And while I don’t want to make this into some anti-cardio diatribe, one of the main reasons why I feel there comes a point of diminishing returns is because you have do MORE of it (steady state cardio) in order to get the same training effect.
As one becomes more “efficient,” they have to do more work in order to burn the same amount of calories.
And just working out for the sake of burning calories is kinda lame. As my friend Bryan Krahn has noted in the past:
Here’s a thought. Say you hit the treadmill for three 1-hour runs per week. What does it do? Well, it burns a bunch of calories, improves your cardio vascular capabilities, yadda yadda. Fantastic. And that’s about it.
Now let’s say you swap the cardio for three 1-hour martial arts classes. You’ll burn a similar amount of calories but also work different movement planes and improve flexibility — things that basic gym training doesn’t address.
(A big part of my training code is to expose yourself to new things, identify any weaknesses, and then address them. I call it having no holes in your game.)
The same mindset can be applied to lifting weights as well. In order for a muscle to grow you need to apply enough of a stimulus to break down the actual muscular filaments – actin and myosin. Assuming ample recovery (and calories) are applied…you progressively get bigger and stronger.
Again, many trainees miss the mark here.
There’s a lack of intentand purpose in the way a lot of people train. I can’t help but think some people feel so long as you walk into a gym and look at a dumbbell you’re going to get results.
This Applies to Life Too
Throwing myself in the spotlight I can think of a handful of scenarios where leaning into some discomfort served a greater good in my life.
Some of you reading will remember a time when meeting someone over the internet was borderline creepy. By today’s standards it’s no big deal, but back in 2004 it would raise some eyebrows.
I met Eric Cressey on the internet.
Eric and I knew each other via various training forums online (most notably T-Nation.com). When he graduated from UCONN he landed a job as a personal trainer in Ridgefield, CT.
I was still in central NY working as a trainer myself and Eric got a hold of me one day and mentioned that he had gotten a job at a gym and that the people who owned it were still looking for another trainer. Knowing that I wanted to get the hell out of dodge, he thought that maybe I should look into it?
I did.
I was hired, and in less than two weeks, despite some major reservations and second guessing myself, I was moving to Connecticut to start a new job with a dude I had met over the internet and whom I had only met once in person.
Understandably, I had to assure my mom that I wasn’t going to get murdered.
In the end, I think it all turned out pretty well…;o)
And then there was the one time my wife, Lisa, had me try a sip of her whisky I had brought home from my trip to Scotland. It was like taking a sip of battery acid. Disgusting. The only thing I grew in that case was more chest hair.
I guess you win some, you lose some.
Discomfort, trying new things, taking risks, doing things differently, challenging yourself…both in the gym and in life.
In general, it’s purposeful use of exaggeration as a rhetorical device or figure of speech. It’s often used in writing (and communication as a whole) to evoke strong feelings and reaction from the audience. These reactions can range from a chuckle and an “aww shucks” eye roll to someone getting punched in the throat.
Hyperbole is everywhere (politics, dating, sports, Thanksgiving dinner) – for better or for worse.
More innocuous and inane examples of hyperbole – the “aww shucks” variety – would be:
I’m so hungry I could eat a horse.
“So and so” is about as intelligent as a ham sandwich.
As a writer I love hyperbole because it can be a useful tool to add a bit of panache and entertainment value to a blog post or article in order to maintain people’s attention for more than 27 seconds.
Where I hate it is where this particular blog post comes into play.
A few weeks ago I was perusing Twitter when my feed fed me this piece of gargantuan eye wash (because, of course):
“STOP DOING BARBELL SQUATS!!! It’s a useless exercise that does way more harm than good to your body.”
This, my dear reader, is a choice example of the latter example of hyperbole mentioned above. You know, the kind that makes you want to wash your eyes with broken glass.
Now, I don’t know the person who wrote it (I’m choosing not to directly mention them here), and I have zero insights into why this person is so vehemently against barbell squats. What I do know – from checking out this person’s profile – is that they’re a Chiropractor, they seem to build a lot of their online persona around this idea that most people lack mental toughness, and that “bad posture” is the reason why most people are in pain.
Not for nothing, but…
…I’d make the case that the reason why a lot of people are in pain is because they’re chronically weak (muscularly), not because their TL junction needs adjusting every two weeks.
(Which, not ironically, can be improved, drastically – and long-term – with some properly progressed strength training.5 If you don’t force the body to adapt to load or stress, then how can you really expect meaningful change? If the only intervention is adjusting and cracking someone’s bones to fit some “textbook perfect posture” narrative, and it’s something that needs to be repeated over and over and over again, to me, this is akin to using nothing but a band-aid to address a knife wound).
But let’s move beyond that.
The thing that rubs me the wrong way with this person’s train of thought is that it’s so egregiously self-aggrandizing. One thing that I despise in this industry – and something that makes me lose a lot of respect for someone when they do it – is thinking that THEIR WAY is the ONLY way to do something.
The easy comparison here is Mike Boyle.
I was in the room when, back in 2005, while recording Functional Strength Coach, he revealed to the strength & conditioning world that he no longer included back squats in his athletes’ programs.
I’m pretty sure this was the collective mood in the room when he said it:
He wasn’t tarred and feathered by the entirety of the profession, but in the years since he’s routinely received flak for his stance.
However, I’ve always respected his take and have never taken issue with it.
Why?
Because he’s never said:
“Stop doing barbell squats with YOUR athletes.”
He’s only said:
“I’ve stopped doing a barbell squats with MY athletes.”
Moreover, he’s always followed that up with a sound rationale & explanation of why he came to that decision in the first place. And whether or not you agree with him isn’t the point:
They’re HIS athletes.
My man is still producing bonafide beasts in the weight-room and on the playing field.
Hard to argue with results.
Bringing things back to our friend from above.
Where I take issue is the insinuation that barbell squats – of any kind, in any situation, with any person, at any moment in time, even if they’re YOUR client and not mine – is dangerous or turning everyone into spinal compression walking balls of dysfunction.
To steal a quote from strength coach Gerry DeFilippo on that matter:
“How about this. Do exercises that fit your anatomical parameters and needs. More information, less fear mongering/cancelling of exercises.”
Our App: From Strength Coach Tony Gentilcore and Psychologist Dr. Lisa Lewis
Most of you may already know that my wife, Dr. Lisa Lewis, Psychologist (and household director of talking about feelings), has been my partner in our Strong Body, Strong Mind initiative:
…to mesh together both physical and mental strength training for optimal health and functioning.
After years of presenting together at conferences, seminars, and private workshops, we are THRILLED to release programming in an easy-to-access, affordable application.
The inaugural program offered in the Strong Body, Strong Mind app is called “Beginner to Badass” and is specifically designed for those who are stark beginners to barbell training or just looking for some direction.
Whether you (or someone you know) is brand new to lifting weights, returning after a break, or just looking for a nuts and bolts program, Beginner to Badass can meet those needs.
What to Expect From the Program
👉 3 months (3x per week; 36 total sessions) of appropriately progressed strength training. NOTE: You will need access to barbells, dumbbells, etc in order to follow this program.
👉 Videos that demonstrate proper technique alongside voice prompts & coaching cues to help you execute every exercise like a pro.
👉 My biceps looking extra bicepy.
👉 A “Mindset Minute” that coincides with every workout session to help you build resilience and persistent habits.
What Not to Expect
❌ Novelty – Exercise variety has a time and place, but a beginner strength training program isn’t one of them. Using one of my more astute and colloquial quotes:
“The greatest gap is most people’s training isn’t lack of novelty, but rather lack of mastery.”
This is the Beginner to Badass program’s glue.
❌ Guarantees or Promises – I could sit here and regal you with grandiose claims like “I guarantee your bench press will increase 50 lbs in five weeks” or “I promise your pecs will be able to cut diamonds” following this program, but that would be disingenuous.
Because the fact is…I don’t know!
What I do know is that you will learn more about what unabashed consistency can do for progress in addition to gaining more confidence including more barbell training to your repertoire.
❌ Lumberjacks – sorry?
We hope you’re as excited as we are to get started.
I’ve been woefully negligent with my writing prowess of late.
But it’s for good reason.
My wife, Dr. Lisa Lewis, and I have been busy for the past few months developing a wellness/fitness app!
Strong Body, Strong Mind
The app is called Strong Body, Strong Mind and we firmly feel it’s going to be quite different than the bulk of fitness apps out there.
How/why?
For starters, the obvious: This app will provide both structured strength training AND mental skills guidance to bolster motivation and confidence.
I’ll be taking the reigns on the training side of the app. The “Beginner to Badass” program is designed to guide those interested in starting a barbell-based strength training program but have otherwise been intimidated to do so on their own.
My goal with this app is to make strength training accessible to the masses and to demonstrate how to properly progress from a beginner to being able to beat Jason Bourne in a hallway battle royale.
Lisa will run the show on the psychological/mindset side. She’s an actual Doctor of Psychology (not an Instagram mindset coach) and has over two decades of experience.
Plus she’s a doctor who actually lifts!
Each workout will have a “Mindset Minute” to coincide with it, and will focus on anything from how to stay motivated when beginning a new exercise routine to ways to overcome speed-bumps with lack of consistency.
In short: Lisa’s there to Jedi mind-trick you into kicking ass and taking names. And maybe, if all goes to plan, get you to summon the force with the strength of your butt cheeks (that’s how it works, right?)
More details will be coming in a few days when the app is officially launched. For now, I hope this serves as a bit of an Amuse Bouche of the awesomeness to come.
But I PROMISE I am going to 1) be brief, and more importantly 2) showcase why it’s important and why it will help you feel better, move better, perform better, and likely turn you into a Jedi Master Spartan Sex God of Minas Tirith.6
The reason I ask is because, ideally, you want to see a 360 or 3D expansion of your ribcage when you take a breath in.
In other words you want to see a little of everything move – chest, belly, back, sides, not eyeballs.
Unfortunately, for the bulk of people out there, this isn’t the case. Many tend to be just be
“chest breathers” or just “belly breathers,” and what ends up happening is a poor Zone of Apposition.
A Zone of Appo Come Again Now?
Zone of Apposition can simply be referred to as alignment. Or, more specifically, it can be described as the act of bringing together or into proximity.
Photo Credit: Postural Restoration Institute (<– AKA smart mofo’s)
If you take a gander at the Optimal ZOA picture (middle) you’ll see a diaphragm that’s domed out as well as aligned (stacked) above the pelvic floor; the ribcage is connected to the pelvis.
Conversely, in the Sub-Optimal ZOA picture (right), the diaphragm is flattened out and the ribs are in a more flared position; they might as well be located in Mordor in relation to the pelvis.
In non-nerd speak: Shit’s all out of whack.
At this point you may be thinking to yourself, “fuck outta here Tony. Who cares? Zone of Apposition sounds more like a term accountants use than anything I need to be worried about. Squats.”
Well, after listening to my colleague, Dr. Sarah Duvall, speak on the matter, here’s why it matters.
A Loss of Zone of Apposition Means:
Decreased core stability, control, respiratory efficiency, and exercise tolerance under fatigue…in addition to postural ramifications.
Increased accessory breathing muscle activity (scalenes, traps, levator), paraspinal activity, lumbo-pelvic instability, low back pain, SI joint pain, and even headaches.
A Quickie Breathing Assessment
Sit down in a chair and place your hands so that your fingers sit underneath and go around the sides of your ribcage.
Inhale.
What happens?
If an alien explodes out of your chest, that sucks.
You should feel LATERAL (into your fingers) expansion of the ribcage with a some motion in your chest and belly too. To steal another train of thought from Sarah, you should think of your breath as the handle at the side of a bucket.
As you take a breath in the handle should move out – LATERALLY – away from the bucket. This is a brilliant analogy for your ribs expanding.
Too, another overlooked aspect of the breath is what’s referred to as the High Hinge Point. This is the area that’s just underneath the bra line.
Can you (or your clients) expand air into this area.
Normal ZOA. Uncanny Jackedness.
Sub-Optimal ZOA (High Hinge Point). Still Uncanny Jackedness
Breathing into the back is an arduous and foreign task for many people, but it’s a key element to improving the ZOA.
Here’s a nice drill to help with that which I’ve used many times with my postpartum clients (as well as those attempting to resolve nagging low back or shoulder issues; encouraging the ribcage to move/expand works wonders for many people).
And That’s That
I suck at writing conclusions. To summarize:
1. Work on LATERAL rib motion.
2. Consider a high-hinge point in people and work to promote back-body expansion as well.
3. My wife and I bought the yellow chair on Wayfair in case anyone’s wondering…;o)
Forget the more esoteric nuances of things like Heart Rate Variability, the efficacy of cold baths, or whether it’s better to follow a concurrent or linear periodization training program for best results.
For superior results in the weight-room I’d make the argument that the ONE thing many lifters fail to appreciate and understand is that easy training is goodtraining.
This past weekend I had the lovely experience of performing a rap battle presenting (alongside my wife) at the Raise the Bar Conference in Dallas, TX.
One of the key talking points I attempted to drive home during our talk was this idea that easy training is good training.
I love to explain it like this:
10% of your workouts you’re going to feel like Mick Jagger on cocaine. I.e., The weights will just fly up and you’ll make a run at a PR (or two).
10% of your workouts you’re going to feel like Mick Jagger the day after. I.e., You feel like you got run over by a Mack truck. I.e., warm-up weights feel like they’re cemented to the floor.
80% of your workouts are the ones where you go in and just do the work. You show up, get your reps in, and leave.
I’d argue for most people, most of the time, they should leave the gym wanting more. This is what 80% workouts are all about.
Don’t get me wrong: there’s a time and place for workouts and/or programs that exist solely to be ass-kickers and make you hate life:
Smolnov
German Volume Training
Sheiko
Anything involving a chain saw.
The thing to consider, though, and what many fail to recognize, is that programs like the ones mentioned above are designed to be done once a year (if that) and only for a fraction of time.
A small window of hell if you will.
They’re not designed to be done week in and week out for an extended length of time.
I mean heck, if you don’t believe me, take a deep dive into many of the most popular (strength) training programs of all-time (5/3/1, Juggernaut, Cube Method, any of Travis Mash’s programs). If you dissect any of them you’ll find the bulk of the work being done in those programs is in the 75-85% of 1RM territory.
Nothing hardcore or extreme to say the least.
It’s smart training, designed to ensure people feel fresh, recovered, and ready to attack every training session without, hopefully, all the bumps and bruises along the way.
In short: Focus on those 80% workouts. The ones you do on a random Thursday. Those are where you actually make progress over time.
Coming Soon – Strong Body, Strong Mind App
(The first app to combine BOTH strength training AND Mental Skills together from myself and Dr. Lisa Lewis)
Go HERE to learn more and be the first to know when it’s available.
The topic of low back pain (LBP) – how to assess it, diagnose it, and how to treat it – can be a controversial one. I italicized the word “can” because I don’t feel it’s all that controversial.
Cauliflower as an option for pizza crust or Zach being chosen as the bachelor on the current season of The Bachelor (when it’s 100% clear that a ham sandwich has more charisma) = controversial.
Simple stuff to consider to help with one’s LBP = not so much.
The topic of low back pain and how to address it is controversial because there’s no one clear approach or answer to solve it.
(And if the last 3+ years of this pandemic dumpster fire has taught us anything it’s that we looooooove to argue over what’s best and what works).
SPOILER ALERT: Everything and nothing causes LBP.
Have ten different doctors or physical therapists work with the same patient and it’s likely you’ll get ten different opinions as to what the root cause is and what tactics need to be implemented to resolve it.
One person says it’s due to delayed firing of the Transverse Abdominus (TA), while someone else states it’s due to someone’s less than great posture or tight hamstrings.
For the record, all are weak excuses at best.
The culprit can rarely be attributed to any ONE thing.
But it’s amazing how often “tight hamstrings” is the fall guy.
Low back pain? Tight hamstrings.
Knee hurts? Tight hamstrings.
Have Type II Diabetes? Tight hamstrings.
Brown patches on your front lawn? Hamstrings.
It’s uncanny.
I mean, I could just as easily sit here and say in worse case scenarios LBP results from drinking too much coffee. I have zero evidence to back that up, but whatever.
…neither do most of the other “culprits” people tend to use as scapegoats.
So, why not coffee?
Or Care Bears for that matter, those sadistic fucks.
What works for one person, may exacerbate symptoms for someone else. And as my good friend, Dr. John Rusin notes:
“Fact of the matter is: there is NO one right way. it’s a big mistake to lump all LBP into the same category and even a bigger mistake to assume all of it presents the same or should be treated the same.”
There’s no way for me to write a thorough blog post on such a loaded topic; especially one that will make everyone happy.
It’s impossible.
I have better odds at surviving a cage match with an Uruk-hai.
Part of me feels like the proper response to the question “what causes low back pain and what’s the best way to address it?” is this:
Most people reading aren’t clinicians or physical therapists. There’s very little (if any) diagnosing going on in the hands of a personal trainer or strength coach. And, truth be told, if you are a personal trainer or strength coach and you are diagnosing, YOU……NEED…….TO…….STOP.
Just stop.
It’s imperative to defer to your network of more qualified (and vetted) fitness/health professionals whom you trust to do that.
However, it’s important to also consider we (as in personal trainers and strength coaches) are often the “first line of entry” into the medical model. We’re the first to recognize faulty movement patterns, weakness, imbalances, and bear the brunt of questioning from our clients and athletes when they come to us with low back pain.
There’s quite a bit we can do to help people.
What follows is a brief look into my mind and what has worked for me in the past with regards to LBP; a Cliff Notes “big rock” brain dump if you will.
Sorry if I offended anyone who likes Care Bears.
1) Rest Is Lame
My #1 pet peeve (and many agree with me) is that “rest” is the worst piece of advice ever.
“Go stick your finger in that electrical socket over there” would be better.
This isn’t to say there aren’t extenuating circumstances where taking a chill pill is absolutely the right choice; sometimes we do need to back off and allow the body a window of time to heal or reduce pain/swelling/symptoms.
That said, I think it’s lame when a medical professional tells someone to “rest,” or worse, informs them that they’ll need to learn to “live with low back pain.”
It’s a defeatist attitude and will spell game over for many people. Before you know it they’re living on a foam roller and thinking about a “neutral spine” while washing their hands.
(NOTE: I am not anti-teaching neutral spine to people. It’s a lovely starting point for most people, but at some stage people need to learn to move in (and out) of precarious positions…because that’s life).
A common theme reverberated in the S&C community is to say “strength is corrective.” I wholeheartedly agree with this sentiment. In fact, why the hell has this not been made into a t-shirt yet?
However, I think a slightly better moniker may be to say:
“Movement is corrective.“
We can use movement (and yes, strength) to help people get out of pain. Rest has its time and place, but I find stagnation to be more of a problem.
The body is meant to move and is wonderfully adaptive. And that’s the thing: adaptation and forcing the body to react to (appropriate levels of) change and stress is paramount to long-term success with LBP.
Sitting on a couch watching Divorce Court in the middle of the day isn’t going to help.
2) Move, But Move Well
I was watching Optimizing Movement with Mike Reinold recently and he noted there are three key elements to movement and why someone may not do it well:
Structural Issues
Coaching/Technique
Programming
It’s important to understand that, in this case, everyone is a unique snowflake.
Structure: Anatomically speaking there is huge variance amongst the population. Hip structure, for example, can have a large effect on someone’s ability to squat to a certain depth or get into certain positions. Likewise, who’s to say the hips are always the culprit? Even upper extremity considerations – like one’s ability to bring their arms overhead (lack of shoulder flexion) – can have dire consequences on back health.
The body likes to use the path of least resistance (also the most efficient) to accomplish any task. However in this case, “most efficient” doesn’t mean best. As Reinold notes:
“Efficient in this case refers to energy, not movement.”
Lack of shoulder flexion will often lead to compensation via more extension through the lumbar spine. It’s efficient movement, but it’s not better movement.
Coaching/Technique: I’m a firm believer that everyone should deadlift (it’s a hip hinge, learning to dissociate hip movement from lumbar movement, doesn’t mean we have to load it), but I don’t feel everyone should do it from the floor or with a straight bar.
Cater the exercise to the lifter, not the lifter to the exercise.
More on this below.
Programming: If someone lacks hip flexion why have them conventional deadlift? If someone lacks shoulder flexion why have them perform overhead pressing or kipping pull-ups? Some of the onus is on YOU, dear fitness professional.
Find what actions hurt or exacerbate symptoms, and stop doing it.
I know I just blew your mind right there.
For example:
1. Client says “x” hurts, and then places their body into some pretzel like contortionist position that would make a Cirque du Soliel performer give them a high-five.
Me: “Um, stop doing that.”
2. But that could also mean addressing how they walk or how they sit in a chair. Someone with flexion-based back pain, will like to be in flexion, a lot.
Maybe taking them through a slump test will offer some pertinent info.
Have them start in a “good” position:
Then, have them purposely “slump” into excessive flexion:
Someone who is flexion intolerant – despite preferring to be in that position – will often say this causes pain.
Ding, ding, ding.
So, the “fix” is to coach them up and try to keep them out of excessive spinal flexion. Cueing them how to sit in their chair and to get up (wider base of support, brace abs, chest up), building spinal endurance (and strength) via planks, and having them hang out in more extension may be the right path to take.
3. On the opposite side of the spectrum is extension, which is often a problem in more athletic populations and in those occupations requiring more standing (ahem: personal trainers/coaches).
Here you might put them into extension and see what happens.
Much like people who are flexion intolerant “liking” flexion, those in excessive extension will like to live in extension.
This will likely hurt.
Finding their spinal neutral is key too.
Hammering spinal endurance/strength via planks (done well) still hits the nail on the head, as does nudging them towards exercises that emphasize posterior pelvic tilt (much of time cuing people NOT to excessively arch during their set up on squats and deadlifts), and even drills that promote spinal flexion…albeit unloaded.
Spinal flexion doesn’t always have to be avoided. In fact, it’s sometimes needed.
Either way, meticulous attention to detail on finding spinal neutral – or pain from ROM – is huge. Once that is addressed, and symptoms has subsided, we can then encourage them to marinate in more amplitude of movement, taking them OUT of spine neutral (cause, it’s gonna happen in everyday life) and use the weight-room to help strengthen those new ROMs.
But I digress.
4) Don’t Treat People Like a Patient
I know this will rub some people the wrong way, but I still use the deadlift for the bulk of people I work with you have LBP.
Nothing sounds so absurd to me than when I hear someone say how the deadlift is ruining everyone’s spines.
To recap:
Deadlift = hip hinge.
Hip Hinge = learning to dissociate hip movement from lumbar movement.
Mic drop.
Resiliency is key in my book. And not many movements make the body more resilient than the deadlift or any properly progressed hip hinge exercise catered to the individual’s goals, injury history, and ability level:
Assuming I have coached someone up enough to understand spinal neutral and they’re able to maintain it, why not poke the bear and challenge them?
A deadlift doesn’t always mean using a straight bar and pulling heavy from the floor until someone shit’s their spleen.
I can use a kettlebell and band to groove the movement:
I can also use a trap bar, which is a more user-friendly way of deadlifting as it allows those with mobility restrictions to get into a better position compared to a straight bar.
https://www.youtube.com/watch?v=p-sA3PG1kGY
Too, I have found great success with various other exercises:
Farmer and Suitcase carries
Shovel Holds
“Offset” loaded exercises like 1-arm DB presses or 1-arm rows, lunges or RDLs (where you hold ONE DB to the side and perform the exercise). It’s a great way to increase the challenge to the core musculature.
Or even outside-the-box exercises like Slideboard Miyagi’s
So long as we’re staying out of precarious positions or those positions which feed into the issue(s) at hand, we’re good.
Find a training effect with your clients/athletes.
Help them find their TRAINABLE MENU.
And That’s That
People have low back pain for a variety of reasons: They’re too tight, too loose, too weak, have poor kinesthetic awareness, or they’re left handed.
The umbrella theme to remember is that there is never ONE root cause or ONE definitive approach to address it across the board. However, that doesn’t mean there aren’t some “big rock” things to consider that will vastly improve your’s and their chances of success.
NOTE: There’s only a few more days to get my latest continuing education resource – Strategic Strength – at $50 off the regular price. Today’s post discusses one of the main topics covered in the course: Assessment.
Assessment.
People don’t like the feeling of being judged – especially by complete strangers.
However, when it comes to working with a coach or personal trainer for the first time, an “assessment” is pretty much standard procedure; a means to an end with regards to collecting data to better ascertain someone’s starting point.
In Short: An assessment guides the coach to help figure out the safest and most efficient path for a client to reach his or her’s goal(s).9
That being said…I feel many of us are approaching assessment the wrong way.
I am not writing this as an attack against assessment
Likewise I am also not here to say one way or the other how you should assess your clients.
You know your clients/athletes better than I do.
I don’t care if your assessment of choice is the Functional Movement Screen, the Selective Functional Movement Assessment, PRI (Postural Restoration Institute), DNS (Dynamic Neuromuscular Stabilization), FRC (Functional Range Conditioning), whatever institutions like NASM or ACE prefer, or, I don’t know, duck-duck-goose.
Everything has it’s strengths and weaknesses.
More to the point, I would think that as people progress through their careers they’d take it upon themselves to actively change their minds the more they learn and gain experience.
They’ll experiment more and eventually “cherry pick” from several modalities to best fit their philosophy and approach to training.
Ideally “assessment” should be a smorgasbord of reaches, rolls, carries, squats, hinges, toe touches, twists, presses, and bicep curls (<— only half kidding on that last one), among other things.
Here is Gray Cook’s definition of assessment (a good one, mind you):
“In the assessment you take your education background, your professional wisdom, the particular situation, the time constraints, other historical information like a medical history or previous problems…and put all that together. That’s an assessment.”
Pretty hard to disagree with that, right?
Here’s my lame attempt:
“Can the person sitting/standing in front of you do stuff?”
I’m not tossing darts at everyone, but I do find that the bulk of fitness professionals out there use the initial assessment as an opportunity to search every crevasse (not that crevasse, get your mind out of the gutter), nook & cranny, and area of the body for “dysfunction.”
Many use the assessment as an opportunity to demonstrate to someone how much of a walking ball of fail they are.
“Okay Mr. Jones here’s what we got: your hip flexors are tight, you have forward head posture, you lack frontal plane stability, you lack ample scapular upward rotation, your left big toe has zero dorsiflexion, you have weak glutes, you’re quad dominant, your shoulders are slightly internally rotated, you’re probably gluten intolerant, your wife is cheating on you, and I’m about 37% convinced you have cancer.
If you purchase a 24 pack you’ll save $13 per session. Whataya say?”
Some of the above may be relevant and stuff you should focus on as a trainer. I mean, I’m not going to sit here and belabor a coach for wanting to improve a client’s thoracic spine mobility.
However, if I were the person listening to some laundry list of things I suck at or need to improve on, I’d be like………
………..”fuck off.”
Be Careful of Being Told to “Fuck Off”
There’s much I can wax poetic on when it comes to the topic of assessment. My biggest pet-peeve, though, is when coaches/trainers place waaaaaaaaaay too much emphasis on someone’s resting/static posture.
Lets revisit the picture from above.
Many high-end gyms implement this advanced form of “postural assessment” as an up-sell to seduce more people into purchase training.
Said individual stands in front of a giant gridded screen and is then hooked up with a bunch of probes and what not that are placed at strategic locations around the body that bloop and bleep.
It’s reminiscent of one the most terrifying movies I have ever seen, Fire in the Sky.
Remember that one?
You know, that alien abduction movie from the early 90’s where the main character is relentlessly poked and prodded by a bunch of aliens on their spaceship?
It’s terrifying.
Anyway, I can’t help but be reminded of that movie whenever I see someone being told to stand in front of a grid so some trainer can scrutinize every inch of their posture in the hopes they’ll be hired to “fix” it.
Who says it needs to be fixed in the first place?
I’m reminded of a photograph shared by Fort Worth, TX based physical therapist, Dr. Jarod Hall a few years back which hammers home my point.
Here’s what he said/posted:
“I want everybody to look closely at this picture and tell me what you see…”
“I see 20 of the world’s top athletes that have tremendous range of motion, strength, body control, and physical capacity… Yet all have significant variances in their static posture as determined by the holy grail plumb-line.
Static posture is near worthless to measure for injury or pain prediction.”
Placing all your eggs into one basket – in this case static posture, which a lot of fitness professionals do – is unfortunate.
Posture is a Position, It’s Not a Death Sentence
To steal from another really smart physical therapist, Dr. Quinn Henoch, “posture will always be relative to two things:
the task at hand
and the load
If you’re not taking into consideration those two things during an assessment – in addition to movement, repetition, speed, etc – and you’re only assessing people based off static posture, well, you’re not smart.
The question, then, is….”what should an assessment look like or consist of?”
