Understanding High-Risk Exercises

1. Understanding High-Risk Exercises

2. To Do, Or Not To Do • "If it doesn't make scientific sense, and it defies common sense, then it must be nonsense.”(Nick Tumminnelo) • You must determine the risk of any exercise by considering the following: • The individual you are working with • What the exercise can, or cannot, do in terms of accomplishing goals • Flexibility • Stabilization • Endurance • Strength • Power • Human Anatomy and Biomechanics

3. To Do, Or Not To Do • Effective and safe exercise design requires you to weigh all the pros and cons of each exercise-risk versus benefit-and then to personalize each exercise choice to the individual client

4. Contraindicated Exercise • Definition: high risk exercises that may increase joint structure damage or soft tissue injury, or might increase the likelihood of a specific population having a heart attack or stroke • Example: Clients with high blood pressure performing isometric exercises

5. Black-and-White Answers Do Not Exist • An exercise that is considered contraindicated for the average, deconditioned individual, might be appropriate for an athlete with sport-specific needs • Example: Plyometrics • An exercise that is characterized as safe for everyone probably isn’t

6. High-Risk Exercises • High risk exercises are based on joint mechanics, mechanisms of injury, and injury predisposition • Joint biomechanics research indicates that certain movements produce significant stresses and those same motions are involved in common injury mechanisms

7. High-Risk Exercises • Always seek to understand why the risk of an exercise is high for a given person or population, and how it can be lowered

8. High-Risk Upper Body Exercises • Chest Press performed at extreme angles • DB Fly • Pec Deck Machine • Upright Row • Dip • Overhead Shoulder Press Behind The Neck • Lat Pull-Down Behind the Neck • Wide Grip Lat Pull-Down • Supine DB Pullover • Unsupported Bent Over DB Row • Lateral Raise • Preacher Curl, Machine Biceps Curl, BB Curl

9. How “Deep” Should a Chest Press or Fly be Performed? • Extreme angles at the glenohumeral joint under load are not advisable • This places the joint in a loaded, horizontally abducted position, which puts the glenohumeral joint at risk for injury

10. How “Deep” Should a Chest Press or Fly be performed? • In other words, hyperextension of the shoulder behind the midline of the body places excessive stresses on the acromioclavicular joint during pressing movements • The ability of the pectoralis major muscle to produce force decreases which leaves the joint vulnerable to injury • The joint is literally being held together by weak shoulder muscles and ligaments

11. How “Deep” Should a Chest Press or Sly be Performed? • Any exercise that places the elbow behind the midline of the body places the shoulder at a mechanical disadvantage that may contribute to rotator cuff injury or anterior shoulder instability • Regardless of body position-supine, standing, or seated-the cue should be that the elbow should not be greater than 90 degrees

12. DB Fly • When the DB fly is performed with a neutral grip this places the glenohumeral joint in a loaded, horizontally abducted position, which puts the shoulder joint at risk for injury

13. DB Fly • To avoid potential injury, perform the exercise with a pronated grip throughout the movement  • The hands should be seen, rather than disappearing • Pectoralis major does not work efficiently from an extremely stretched or horizontally abducted position under a load • When the shoulder is in this position the rotator cuff muscles are placed at risk of injury

14. The Pec Deck • This exercise is performed by sitting at the machine with your back flat against the back pad, placing your forearms on the padded levers and positioning your upper arms parallel to the ground, while pushing the levers slowly together

15. The Pec Deck • It places the shoulder in extreme positions under load (external rotation and 90 degrees of abduction) and decreases a large percentage of pectoral involvement • This exercise may cause glenohumeral instability and stress • Bringing the elbows together usually causes excessive neck flexion which loads the cervical spine

16. Upright Row • This exercise causes poor alignment of the wrists, elbows, and shoulders • Internal rotation of the shoulder is combined with abduction which increases the risk for shoulder impingement • When the shoulder is extremely internally rotated, bone or cartilage comes in contact with bone

17. Upright Row • Upright rows may accelerate rotator cuff degeneration. • You can risk developing chronic tendonitis or bursitis

18. Dip • The elbow is behind the midline of the body which forces the shoulder into excessive extension under load • This can create wear and tear on the glenohumeral joint when performed with chronic regularity • The presence of muscular imbalances increases chances of injury

19. Dip • The concentric phase of the exercise puts vertical stress directly on the acromioclavicular joint which can cause separation

20. Overhead Shoulder Press Behind The Neck • Extreme shoulder external rotation and abduction under load stresses the glenohumeral joint which can cause anterior shoulder stability • The neck is usually excessively flexed which loads the cervical spine

21. The Lat Pull-Down Behind The Neck • When the bar is pulled behind the head, the neck must excessively flex (which loads the cervical spine), and the shoulders are forced into extreme external rotation • This can contribute to rotator cuff injury or anterior shoulder instability

22. Wide Grip Lat Pull-Down • An excessively wide grip does not work the “outer lats” but can increase shear (horizontal force on the joint) forces across the glenohumeral joint as well as limiting ROM at the shoulder

23. Supine DB Pullover • This exercise forces the shoulder to flex under a load which causes anterior glenohumeral joint instability • This exercise can also stretch the connective tissue that forms the linea alba. If the linea alba tears, you have a hernia of the median rectus, which produces a slight bulge in the center of your abdominals that increases in size when you strain

24. Unsupported Bent Over DB Row • The risk of injury and cumulative stress to the spine may be high, particularly if the spine is flexed • This posture is passively supported by ligaments and fascia in the low back

25. Unsupported Bent Over DB Row • The stabilizing muscles of the spine are not in a good position to exert force in this position because muscle activity of the spinal extensors decreases • The spine can only resist the force of the weight being lifted through ligament and fascial support • There is a potential shearing force on the disks positioned between the vertebrae of the spine

26. Lateral Raise • Lifting too much weight, keeping the arms straight, and raising the arms out away from the body in the plane of the body may cause stress on the rotator cuff muscles

27. Lateral Raise • The proper way to execute a lateral raise is to keep the elbows comfortably flexed (20-30 degrees) and raise the arm to no higher than parallel to the floor. • The arm should be in the scapular plane of motion (approximately 30-45 degrees from being perpendicular to the body) and the weight should be relatively light

28. Preacher Curls/Machine Biceps Curls/BB Curls • When you supinate the forearm to grab a bar or a fixed grip handle, the forearm deviates laterally in relation to the humerus, which accounts for the anatomical carry angle • Supinate your hands and note the lateral angle • This is your individual carry angle.

29. Preacher Curls/Machine Biceps Curls/BB Curls • If the anatomical carry angle is not taken into consideration when curling you may experience pain in the forearm

30. Preacher Curls/Machine Biceps Curls/BB Curls • Any time you train with your hands fixed to a bar or a fixed machine you must follow your anatomical carry angle • If this adjustment doesn’t help, stay away from bars or fixed machines • Training with cables or dumbbells allow for right/left handed independency; therefore, obeying an individual’s carry angle by enabling the forearm to adjust during an exercise

31. High-Risk Lower Body Exercises • Squats performed at extreme angles • Sumo (Plie) Squats • Smith Machine Squat • Hack Squat Machine • Leg Press Machine • Knee Extension Machine • Straight-Leg (Stiff-Leg) Deadlift • The Good Morning • Hip Adductor Machine and Hip Abductor Machine • The Hurdler’s Stretch

32. Squat Depth • The normal range of knee flexion is 0-135 degrees, but when you add a heavy load the risk of injury increases • Encourage clients to approach 60-90 degrees of knee flexion when performing squats, lunges, leg presses, and wall squats • The compressive forces on the back of the knee cap increases as the knee moves from 60 toward greater degrees of knee flexion • High compression forces can cause wear and tear on the articular cartilage

33. Squat Depth • At 90 degrees the knee takes on three times the compressive force as measured in body weight • The more weight being lifted, the more compressive force present at the joint • Beyond 90 degrees stretches the posterior cruciate ligament within the knee joint, which can destabilize the joint

34. Sumo (Plie) Squats • Most people feel this exercise in their glutes • Prolonged use of this exercise may lead to increased low back pain, knee pain, and ankle/foot pain • The sumo squat requires that the individual laterally rotate their hips, placing the gluteus maximus in a shortened position • The glutes in this position (shortened) are not able to generate maximal force

35. Sumo (Plie) Squats • As a result, this can lead to synergistic dominance (when a helper muscle takes over for a weakened prime mover) • In this case, the piriformis and the biceps femoris may become synergistically dominant • When these muscles become dominant, they alter the way the low back, hip, knee, and feet move – predisposing you or your clients to low back pain, sciatic nerve pain, lateral knee pain, and plantar fasciitis (mid-foot pain from increased pronation)

36. Smith Machine Squat • Fixed plane of motion- it forces you to follow the machine's straight line of motion rather than the natural arc developed by the lumbo-pelvic hip complex • The machine forces you to move the bar on a straight line while your body is planted in one spot. This is not a natural movement pattern

37. Smith Machine Squat • If you put your feet forward, to reduce knee flexion, the lower back is put in a weak position, with rounding of the lower back likely. • In addition, there may be additional stress on the knees as the feet want to slide forward but don't because of the friction from the floor surface.

38. Hack Squat Machine • Causes patella femoral shear • Patella rubs against femur • Forced plane of motion • Alternative: squatting against the wall with a stability ball

39. BB Front Squat Versus BB Back Squat and Leg Press • BB Front Squats decrease spinal load (torque, compression, and flexion) and improve back posture • BB Front Squats are safer than the BB Back Squat and Leg Press • Three major reasons people still do BB back squats and leg press versus BB front squats: • They always have (people really hate change) • They can lift more weight (ego is always a big problem) • They perceive front squats as difficult due to poor wrist flexibility

40. Leg Press • The potential danger in this exercise is seen when you bring the knees in close to the chest on the eccentric phase. This rounds the lumbar spine and increases the pressure on the spinal discs. The high compressive forces can cause the discs to herniate (rupture) • Is this exercise really functional? Where in real life do you have to push out with your feet to move a heavy object and your back is locked? • If you cannot squat properly, have low back or knee pain do not use the leg press

41. Knee Extension • Unlike the squat, the load is placed at the ankle that results in force being exerted across the hinge joint • This is like hanging an excessive weight on the top of an open door • Eventually, the force would cause the door hinges (the knee) to creak and grind and not operate smoothly

42. Knee Extension • It may cause injury to the tibiofemoral joint and anterior cruciate ligament (ACL) of the knee

43. Straight-Leg Deadlift • Improper form can cause injury • Failure to keep the back in neutral during the movement causes undue stress to the spine forcing the internal fluids to compress towards the back, and potentially causing a disk to herniate • This is especially true of the lumbar region of the spine, which is designed to bear the bulk of the compressive forces on the upper body • In addition, the compression can squeeze the spinal roots of the spinal cord, causing nerve conditions like sciatica

44. Straight-Leg Deadlift • The depth of this exercise is dependent on hamstring flexibility and the ability of the back musculature to stabilize the spine • Alternative: Single-Leg Deadlift or Romanian Deadlift Would you teach your clients how to pick up an object off the floor like this?

45. The Good Morning Exercise • Placing resistance behind your neck creates an unacceptable shear, destabilizing force across the spine • The risk of injury to the spine is high! Say Good Morning To Your Orthopedic Surgeon!

46. Hip Adductor and Abductor Machine • Forced plane of motion • The hips must simultaneously rotate and rise laterally or medially • These actions place great stress on the lumbar spine, especially when heavy weights are used • The danger is even greater if the movement is done quickly, with a jerk, or if there is excessive hip rotation when the leg is out in front of the body

47. Hurdler’s Stretch • The awkward knee position in the bent leg creates stress on the medial collateral ligament and may promote medial knee instability • It may stretch the knee ligaments • It may result in misalignment of the patella • May injure the lumbar spine

48. High-Risk Trunk Exercises • Sit-Up • Sit-Up Machine • Supine Leg Raise and Hanging Leg Raise • Scorpion Twist • 90-90 Trunk Rotation (Windshield Wiper) • The Iron Cross (Hip Cross Over) • Seated Trunk Twist • Cobra • Superman

49. Sit-Up and Sit-Up Machine • When the feet are fixed or the thigh is stable the origin of the hip flexors are pulled toward the insertion, causing compression and sheer force on the spinal disks, and resulting in a movement where the trunk moves toward the femur

50. Supine Leg Raise and Hanging Leg Raise • The majority of the movement is done with the hip flexors • Trunk hyperextension may injure the lumbar spine