Do Coaching Cues Matter for Pain & Injury Prevention?

I recently made a post on Instagram that upset some physical therapists, strength coaches, and pain scientists, who felt I wasn’t being evidence-based. Although I’ve read a lot of research on the topic of injuries, pain, and so forth, much of what I do as a strength coach is buried in tradition. This is the way I learned, so this is the way I teach, and here are the coaching cues I use. But what if there’s a better way? How would I know? It’s hard and arguably unethical to experiment with clients and “roll the dice” with regards to things that could potentially cause injuries in the gym. Now, I will confess to not believing that buttwink and knee valgus are that risky in terms of causing injuries. But spinal hyperextension and certainly spinal flexion – I’m more concerned about.
Nevertheless, I invited two of my most-knowledgeable-colleagues to attempt to refute some of my beliefs. I tried to be as authentic as possible and pull no punches (yeah I’m being a total prick with my statements). But I have a feeling that many other strength coaches feel the same way.
I am absolutely willing to change my mind over time. It’s just that every time one of my Glute Squad members hurts their lower backs – it’s because they rounded too much in the deadlift with heavy loading. Or they did too many reps of hip thrusts with too big of an arch. Or they went too deep in the squat and buttwinked a litle too much. Or a combination of them and the back just gets funky.
What I absolutely don’t want to be guilty of is unnecessary fear mongering. I don’t want people thinking that the spine can never move; it does. It always does. I first pointed this out in my blog post on Anterior Pelvic Tilt in 2015. Even if you think it stays neutral, it doesn’t. And my first published study in 2011 titled To Crunch or Not to Crunch (also an accompanying TNation article to go with it) cast doubt on the spinal flexion literature pertaining to crunches; I don’t buy into the hype that crunches cause injury. Now, crunches are different from maximal deadlifts in my opinion, but the point is, it’s good to challenge the status quo.
Without further ado, please welcome my colleagues Adam Meakins and Greg Lehman (please click on their respective links to follow them on Twitter). These guys know the research on pain and injury much better than I do, and they’re fighting a good fight in terms of getting people to not be so dogmatic in the way they view pain with regards to biomechanics. I asked them to challenge my statements below, and thankfully they obliged. The following are their responses:

There is currently no research that examines the longitudinal effects of traditional, accepted form (as taught by strength coaches) versus “poor” form on injuries. For this reason, it is speculative at this point to assume that the cues “chest up, knees out, squeeze glutes, sit back, push through heels, arch the back, don’t shoot the hips up, big breathe, etc.” prevent injuries. But there’s also no research suggesting that these cues do not prevent injuries.

Greg: 

This is true. There is no research looking at good or poor lifting technique and injuries but there is occupational research that has shown that training in proper lifting technique does not decrease injury risk (Sowah et al 2018).  With respect to the knee we can also see that valgus is not a barrier to having healthy knees as there are a number of studies showing that hip adduction and knee abduction (part of valgus) does not change after a successful strengthening rehabilitation program yet pain and function improve (Earl and Hoch 2012).

Adam: 

I agree that the common cues often used in heavy lifting have not been shown to either reduce or prevent risk of injury. They may however help improve performance of effortful exercises.

Given this lack of evidence, until more research emerges, strength coaches should err on the side of caution and go with tradition in order to prevent injuries, meaning provide the typical instructions while coaching athletes.

Greg: 

This is not unreasonable but we can also go with tradition and note that many life-long lifters have lifted with an extremely flexed lumbar spine, have done ass to grass squats that mandate butt wink and therefore 100% lower spine flexion and have used knee valgus to facilitate performance at the bottom of the squat. So if tradition guides us then we need to evaluate who’s traditional technique should we model ourselves after.

Adam: 

I have no issues with coaches using these common cues mentioned above to help people complete effortful exercises. My argument is that these cues do not necessarily help ‘improve’ the biomechanics of effortful exercises, and may just improve their ability and feelings when doing them.

Coaching someone to keep a neutral spine or straight back doesn’t mean they will do this during the execution of an effortful exercise, or that its either necessary or essential to reduce their risk of injury.

While it’s true that pain is complex and involves some combination of biological, psychological, sociological, and biomechanical factors, injury is more simple and is mostly related to physics/biomechanics. In other words, various structures can only tolerate various loads, and once exceeded, strains, sprains, herniations, fractures, etc. occur. Psychology and sociology doesn’t factor into the equation much here.

Greg: 

Yes, tissue can fail at high loads but there are two issues here:

1. You assume that most training related “injuries” are actual tissue failures.  This is not necessarily true.  You can see this because someone can lift 1000s of times with the same technique – if the loads exceeded the tissue’s structural strength then that injury would occur the first time they did this. Now, you might argue that there will be fatigue related injury and the structural strength will decrease over time.  Yes, that’s possible but would also be a factor with any type of lifting technique and the means of avoiding fatigue related tissue failure is to slowly apply stress and facilitate adaption – you know, the whole point of strength training.

2. You are making the assumption that the technique that you are arguing for is actually the position of greatest structural resilience. This is not necessarily true.  That would be subject to debate and again assumes that structural injuries are the actual “injuries” that stop people from training. In high load sports like football we know that psychosocial factors are potential contributors to pain/injury (Mann JB 2016) which again calls into question if true structural failure is the driver of disability and pain.

We see examples of structural resilience in many sports that demand the positions that you call poor. Watch any skateboarder landing from 10 feet in the air.  They have massive amounts of spine flexion and knee valgus.  If you rock climbing you know that a drop knee requires knee valgus and high loads. We shouldn’t be vilifying these positions but accepting that not only are they normal and safe but often optimal.

Adam: 

Whilst I agree that any injury is due to the loads exceeding the capacity of the tissues. I disagree that other factors don’t come into the equation much.

The occurrence of any injury is complex and although mechanical and loading factors are certainly a key aspect there are multitude of confounding factors that may or may not contribute to an injury.

For example its hard to exceed a tissue’s capacity without first having the confidence and mindset to undertake a high intensity effortful task or exercise. Why and how injuries occur is simply black box epidemiology. (Bittencourt et al (2016), Hulme & Finch (2015).

In general, a neutral joint alignment spreads the distribution of pressure and prevents (to the best of the body’s ability) the concentration of stress at any particular structure.

Greg: 

You sure? The neutral position for the knee is upright standing. This is like saying that deep squats are harmful on the knee because you have moved out of the neutral zone. I know you don’t think this so this requires a rethink. If you are worried about staying in neutral then how could you ever press overhead or allow your ankle to dorsiflex? Joints often go to end range or out of neutral but for some reason we focus only on certain joints. And yes, movement at a joint will redistribute tissue loads – we can agree on that.  I think we can only say there is redistribution of stress and stress is catalyst for adaptation. So, I’m not sure why we are worried about stressing other tissues.

Adam: 

Yes it does, but joints do not remain in neutral positions for long when moving or exercising. Therefore, we need to expose joints to various ranges and angles as well as loads and forces for them to be able to adapt and develop resilience to them.

Most weightlifting-related low back injuries occur when the spine is rounded or extended past neutral. For example, rounding the spine too much during deadlifts, or arching the back too hard on hip thrusts (over time).

Greg: 

I reject the premise here but we actually don’t know if this is true and there are other variables that could explain this idea even if it was true. Your spine tends to round the most when the loads are the greatest. Remember, even when you try to minimize spine flexion during a deadlift you will probably still have about 70-80% max flexion.  Someone else might have 95%. In both of these lifters when their spine is most flexed they are probably at the point in the lift where the loads are the greatest.  So, if injury occurs at the most flexed position is it the flexion that is an issue or is it the fact that loads are highest?

The crux and unresolved part of this debate is that you think certain positions might be safe in the short term but in the long term a person can’t adapt to them.  Meaning, certain positions stress certain structures that are better able to adapt. This is worth considering. I respect the position and am comfortable with people disagreeing here because we really don’t know.  Strong opinions on this topic should probably be avoided.

Adam: 

As mentioned, there is no evidence that supports this claim. We do see back pain occurring more in those who undertake physical work, especially in awkward positions, but we also see increased rates of back pain in jobs that are sedentary too. Occupational back pain is also seen to be correlated with job satisfaction as well.

For this reason, and knowing that spinal motion is inevitable during exercise, coaches should cue neutral, knowing that the athlete won’t actually stay in neutral, but they’ll likely prevent too much spinal motion from occurring, which will prevent injuries. For example, reinforce “chest up” over and over in the deadlift so that they never reach full spinal flexion under heavy loading, or reinforce the chin-tuck and forward eye-gaze during the hip thrust to prevent excessive, repetitive spinal hyperextension.

Greg: 

Again, you are begging the question. The research (primarily animal models) that suggests that spine flexion increases the risk of tissue damage typically doesn’t compare 100% max flexion with 30% max flexion. It tends to be less than 70-80% of max flexion of the cadaver motion segment (I’m estimating this – because its hard to tell in the studies but its definitely not max). And in those studies loading the spine with small amounts of flexion (the amount that is absolutely unavoidable) still causes damage.  So, if you think those studies are relevant to humans you would have to say that loading minimal amounts of flexion is injurious. And if you accept that then none of us can advocate squats or deadlifts.  But, we don’t do that.  So, we need an entire rethink on the relevance of that research.

Adam: 

Again, I don’t have any issue with using these common cues for most people when performing effortful exercise. I just don’t think they do what many think they do, and I don’t think they reduce risk of injury.

There isn’t currently much research to suggest that the body can continuously adapt and that all soft tissue structures can continue to strengthen to the point where they can withstand anything the body is capable of doing in the weight room. In theory, Wolff’s Law of Bone and Davis’s Law of soft-tissue would prevail, but in the real-world there’s only so much resiliency/pliability that can be gained in certain structures.

Greg: 

Yes, and this applies to any lifting technique since structures are going to be stressed -that’s the point of training. So, what is probably most important is good programming, recognizing when your athlete needs to back off (perhaps it’s some high psychosocial stressor week), learning the optimal amount of loading for a person and the ability for athletes to be flexible with their training. IOW, don’t train like an idiot and be a Movement Optimist.

Adam: 

There are of course limits to human adaptability and progress, otherwise we would all be running 100m under 9 secs and deadlifting over 500kg. And pushing closer to the boundaries of what humans can do physically often reduces the margin of error for avoiding injury as we get closer and closer to a tissue’s capacity.

For this reason, a coach should simply strive for more neutral alignment with their cueing tactics, rather than employing exercises like progressively heavier Jefferson curls (to theoretically strengthen the discs and ligaments to prevent herniations and strains). 

Greg: 

This is what’s interesting. A deadlift and a Jefferson curl will stress the disc. Compressive loading with 30-80% of flexion will still cause increases in disc pressure and because you lift so much more in a deadlift the compressive loads will be higher than what you see in a Jefferson curl. We also have a few modeling studies out of Shirazi-Adl’s lab that suggest that a more neutral lifting posture does NOT have less disc strain than a more flexed posture. So the idea that a heavy deadlift with 60-70% of max flexion has less disc strain than a Jefferson curl may not be valid.

And sure, there is probably more ligamentous strain in a Jefferson curl because you are going to 105% of max flexion but who cares? You do what, 10 sets of 6 in a week? You are actually concerned about 60 weekly reps?  Seems inconsistent from someone who has no fear of 700 curl ups done in a week which would also have a lot of ligamentous strain.  Oh and guess what ligament gets loaded like mad during squats? The ACL – and guess what happens to it in lifters? It gets stronger and bigger. But no one freaks out about ACL loading in a squat because it’s not an issue.

Adam: 

Both traditional deadlifts and Jefferson lifts expose an individual’s tissues to forces and so will cause adaption if they are within the tissue’s capacity, or injury if it exceeds it.

Different types of deadlifts (or any other exercise) do not inherently have lesser or greater risks of injury, it’s the parameters around them that do.

Every exercise and its variations have different effects on different tissues that should be utilized based on the individual’s goal. If someone needs their tissues exposed to loads in awkward ends of ranges, then a traditional deadlift will not do this whereas a Jefferson curl will. As always, the specific adaption to imposed demands principal reigns supreme here for all structures.

The true experts on strength training form/technique are strength coaches. Physical therapists study injured people or people in pain and aren’t skilled in the art of “bullet-proofing” an athlete who engages in heavy strength training. Moreover, there are things you have to learn in the weight room; they can’t be understood by reading research.

Greg: 

Ha!  Strength coaches are awesome at tweaking form for performance and that is where biomechanics matters the most. Biomechanics and form tweaks are also great for knowing how to bias a structure or muscle to catalyze an adaptation (e.g. you want a bigger booty). But, no one can use their personal experience to comment on injury prevention – you know, to comment on how effective you were creating something that never happened. You have to do research for that.  Otherwise, the Juggling coach/Reiki practitioner/strength coach will say that the reason their athletes didn’t get injured was because of the juggling and Reiki.

Adam: 

Many physiotherapists are also fully accredited and degree trained strength and conditioning coaches, and some S&C coaches are well read and understand injury, pain and rehabilitation. There is a lot of cross over.

Experiential learning is of course a part of life and learning, and many ideas and theories are formed on the basis of observation and experience. However, to truly test these observations and theories they do need to be examined under controlled scientific process to assess their accuracy.

Anything that can be claimed without evidence can also be refuted without evidence.

Suggesting that cueing doesn’t matter for injury prevention is unfair to strength coaches in that it assumes that we’ve laid down a foundation of complete pseudoscience and are wrong about all of the trial and error we’ve collectively undertaken. Think about it…it would mean that every text written on form/technique is wrong or at least highly incomplete. Moreover, it is questionable for those who have never worked with very strong athletes to make conjecture about what we do as coaches.

Greg: 

Again, plenty of strength coaches disagree here. We aren’t a monolith so who’s foundation and experience should people listen to?

What I would suggest is to look at what the common cues are and focus on the common movement variables seen across good performers.  I think spine flexion and knee valgus are red herrings. You will see a lot of variability across good performers and coaches, but you will also see similarities (hip position, hip kinematics, bar path, tension in the system, speed, timing). It’s these biomechanical variables that should be discussed across coaches. And then when good coaches disagree (e.g. toes out/parallel) you need to ask if that is really an important biomechanical principle or one acceptable variation for different individuals.

Adam: 

I am not disagreeing or suggesting that cueing and coaching doesn’t matter, I am saying it’s untested that it’s necessary or sufficient to prevent or reduce the risk of injury, and I haven’t made any conjecture what any coach does or doesn’t do?

Working with strong athletes tells you a lot about strong athletes, and this is useful, but it doesn’t mean that what you see and experience with this population can be extrapolated to other populations.

If a 12-week longitudinal study was conducted where group 1 was trained by certified strength coaches who typically work with strong athletes and utilized traditional coaching and cueing tactics, and group 2 was trained by physical therapists who never worked in a gym and believed that there’s no such thing as bad form and allowed them to lift with whatever technique came naturally to them (no instructions and cueing…just encouragement), and similar progressive overloading occurred in both groups, group 2 would likely experience a glaringly higher number of injuries compared to group 1. And this would help validate what strength coaches do and have learned over time in the trenches.

Greg: 

That would be a neat study, but the results would depend on what “bad form” is allowed. Sure, if you let someone just hammer the shit out of themselves, jerk weights, move incredible faster than what they are used to then maybe that “bad form” group will have more injuries. Again, there are probably things that are “bad form” they just might not be what you think they are.  I think we are focusing on the wrong things.

But if both groups lift at similar speeds, with a similar weight progression that respects effort and training infancy (e.g. don’t do too much too soon dumbass), with similar reps in reserve I think injuries would be similar but performance gains would be less in the Physio group because I doubt the physios would have the skill to push the people when they should be pushed and pull them back when they need to be pulled back – or to be able to coach movement to get the most out of it. But injuries are different.

Remember, “bad form” sometimes is protective. You often can’t lift as much with “bad form”. It acts as brake and the peak loads could be less which again could be an issue for progressing strength or hypertrophy where the person wants it.

Training errors are really a question of total volume. Yes, we can’t adapt forever but technique is the tiniest way to change joint and tissue stress. It’s good training progression and respecting people’s ability to adapt that is most important. So, if those physios can also tailor the loads based on all the life stressors that person has and helps optimize their entire system then we might even see less injuries in that group. I think you are focusing on the wrong variables here.

Adam: 

This is a loaded study design that will more test the coach/physios experience and programming skills rather than the risk of injury due to technique.

What would be a more robust study would be to have a sufficiently matched population, eg: experience age, previous injury history etc,, all perform a matched progressive program of exercise, but one group has very specific instructions, the other with minimal instructions. They are then tracked over a sufficient time period to see the incidence of injuries that occur (which would need to be well defined, e.g. does soreness count, etc.)

Good coaches and physical therapists know that some athletes will never be able to handle certain positions under certain loads. Butt winking in the squat is fine for most people, but not everyone. Same goes for extreme knee valgus while squatting, significant rounding in the deadlift, significant arching in the hip thrust, etc. There’s a strong genetic component to soft-tissue strength, and large anatomical differences which predispose certain individuals to injury far more so than others. Therefore, although general recommendations are fine, nobody should ever recommend certain techniques and postures across the board for everyone. 

Greg: 

If this is true how many athletes do YOU injure in a year to figure out which person has the genetic ability to tolerate those positions? You would have no idea who has the genetic potential to tolerate those positions unless you have tried and they have proven it. I don’t think 23 and me has a butt wink heritage section.

However, with everything that I have said I do recognize that everyone is probably capable of doing too much and creating pain. Thus, I would advocate for options in how you do many of your exercises in particular those with higher repetitions. Be flexible in what you consider “good form” and when a lift is associated with pain for someone you can modify that lift a number of different ways to keep them training. This might involve less spine flexion or extension. For others it might involve more spine flexion. Be a movement optimist.

Much of what I have written is covered in our recent paper Howe and Lehman 2021 – Getting out of neutral. The risks and rewards of lumbar spine flexion during exercises and 6 years ago on my blog.

Adam: 

I agree that there is a lot of individual variation in how people tolerate movements and exercises for a multitude of reasons. Therefore, having a flexible and individual approach to coaching cues and exercise instructions is essential and sensible.

Telling everyone to lift, squat or run the same way is simply not best practice nor evidence based and fails to recognize individual morphological variations and that movement is a dynamical system.

Bret: 

Thank you both for your time and expertise, it is much appreciated. Keep fighting the good fight!

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