The Relationship Between Sagittal Standing Posture and Low Back Pain

Justin Gibson, BS, CSCS

Introduction

            Low back pain is a common and often debilitating condition affecting an average of 12% of all persons at any given time and a lifetime prevalence upwards of 60% of the population across sex, socioeconomic, occupational, and national boundaries (Hoy, et al., 2012). Researchers the world over have searched for underlying causes and contributing factors to low back pain, and the methods and results they have obtained vary substantially from one study to the next.

            One such potential factor is posture. The position and alignment of the lumbar vertebrae is a logical point of interest when studying pain in the region, and as such has been the focal point of many researchers. However, the literature surrounding posture and low back pain is complicated, with a great deal of variety in both defining “posture” and “pain”, and a consensus among researchers is often illusive. In this paper, I will attempt to provide an overview of major studies in the realm of static standing posture in the sagittal plane and its link -or lack thereof- to pain.

Posture and Low Back Pain: The Theory

            All studies begin with a question based on a thorough analysis of the research that came before them. To ask the question, “Does one’s posture affect their risk of developing lower back pain?”, there must be a reasonable theory behind why that might be the case. And, indeed, many studies and textbooks have put forth potential structural and physiological factors linking the two.

            In their study, “Effect of low back posture on the morphology of the spinal canal”, Chung, Lee, Kim, Chung, & Ahn (2000) observed structural changes in the spine when subjects were placed in differing positions during MRI imaging of 20 healthy young volunteers. Using foam bolsters and stabilization belts, the researchers looked at L3-L4 and L4-L5 relationships when subjects were put into neutral, flexed, extended, and rotated positions. They found that the gap between the posterior disc and the anterior margin of the facet joint increased with flexion and decreased with extension or rotation. This narrowing of the spinal canal during extension and rotation, the researchers argued, could potentially explain the posture-dependent symptom of spinal stenosis. However, the authors of this study acknowledge the limitations of measuring the behavior of the spine in a cramped MRI machine, including a restriction of range of motion and the inability to axially load the spine. Still, changes in the spinal canal were observed, and give some credence to the link between certain spinal ailments and certain postures.

            Another study that looked at potential risk factors for postural aberrations was performed by Burnett et al on female rowers. A non-invasive electromagnetic device was attatched at L3 and S2 to measure axial rotation range of motion in different circumstances. For both standing and sitting, subjects achieved the highest degree of rotation in a “neutral zone” determined by the experience physiotherapists guiding the study to be the midpoint between end-range flexion and extension. When the subjects were guided into end-range extension, axial rotation was significantly reduced; the researchers theorized that this was due to the bony stiffness provided by the facet joints of the vertebra. In end-range flexion, axial rotation was even more significantly reduced, this time possibly due to passive stiffness from the posterior fibers of the annulus and the posterior ligaments. The results of the study suggest that in end-ranges of motion, more force may be absorbed by the comparitively less resilient passive structures of the spine rather than the active, muscular structures, and could potentially lead to injury.

            While these studies are useful in determining potential mechanisms for injury during significant flexion or extension, they say little about “natural” standing posture, as most people do not stand with their spines approaching end ranges of either flexion or extension. In fact, “natural” standing postures can be frustrating to study due to the immense variance between individuals. Such was the goal of Claeys, Brumagne, Deklerck, Vanderhaeghen, & Dankaerts (2016) when they attempted to look at correlations between all spinal regions in 99 healthy first year physiotherapy students. These researchers looked at lumbar curve, thoracic inclination, trunk angle, pelvic tilt, lumbar angle, head angle, neck angle, and cervicothoracic angle to any and all correlations between them. What they found with respect to standing posture was that only trunk angle was significantly predictive of other angles, and even then, the correlations were mostly medium to small. In discussing their findings, the authors conclude that optimal posture probably does not exist in a way that can be applied to any large population, and the “optimal” posture for any individual will be heavily determined by genetic and environmental factors unique to them.

            Lastly, even though perfect posture may be undefinable for the population as a whole, we can at least identify certain patterns in standing postures that make defining different postures possible. Researchers appear to have no set consensus on what categories of sagittal plane posture should exist, and the studies presented in this paper use a mixture of quantitative and categorical variables in attempting to do so. One such category of standing posture is sway, which is seen in O'Sullivan, et al. (2002) and in Smith, O'Sullivan, & Straker (2008) and is defined, loosely, as an anterior shifting of the pelvis resulting in a posterior trunk lean. In the former study, muscular activity was measured in sway standing as compared to neutral standing (neutral, here, was defined as having markers on the acromion, greater trochanter, and lateral malleolus stacked in a straight line on top of one another). Sway posture was of interest to the study because it was deemed a “passive” posture that one might adopt to save energy by relying on passive structures of the body rather than active ones, akin to a slumped sitting posture (which was also measured in this study). The researchers found that muscle activity changed dramatically between neutral and sway postures: the lumbar multifidus, internal oblique, and thoracic erector spinae all showed a significantly decreased activations  when the subject shifted into the sway posture, replaced by a significant increase in rectus abdominus activity. When discussing the clinical relavence of these findings, the researchers speculate that individuals who habitually adopt passive postures deactivate and potentially decondition the stabilizing muscles of the lumbopelvic region, which may leave it vulnerable to strain, instability, or injury.

            To summarize the theory behind looking at the relationship between posture and low back pain, we see in the research that as the spine moves further away from “neutral” postures (individualistic though they may be), it relies more on passive structures to absorb force rather than the more resilient active structures. These deviations may also decrease the space in the spinal canal, which can potentially increase the risk of certain spinal ailments such as stenosis. However, most individuals do not approach end-ranges of motion in their normal standing posture, and as such the happenings-on at these ranges may be of limited use.

Correlations in Observational Studies

            Though flawed, there is enough evidence linking posture to potential mechanisms of low back pain to have warranted many studies on the subject. The most common way to study most correlations is through observational studies, which attempt to find commonalties between or across groups at a set point in time, without establishing any cause an effect relationship. Though not experiments, they can be useful in identifying potential links between two variables.

            An author of one of our previous studies about sway postures, O’Sullivan, who also took part in a similar study linking that posture and others to low back pain in adolescents. Specifically, the authors divided subjects into sway, flat, hyperlordotic, and neutral categories. What they found was interesting: subjects with non-neutral postures demonstrated higher odds for all measures of back pain, but no one posture was consistently associated with pain in isolation (Smith, O'Sullivan, & Straker, 2008). For instance, males with sway posture were more likely to have back pain lasting three months or more, but females with this same posture were no more likely to experience pain than those with neutral posture. Likewise, females with a flat posture were more likely to have pain aggravated by sport, but males were not.

            Indeed, the issue seems to be more complicated than a one-to-one relationship between static standing posture and low back pain. A different study on adolescents showed no correlations between postural displacements and back pain using the PosturePrint internet-based computer system (Ozyurek, Genc, Karaali, & Algun, 2017). One study finds an association with a loss of lumbar lordosis (Jackson & McManus, 1994), and another study finds an association with an increase in lumbar lordosis (Christie, Kumar, & Warren, 1995).

            One study, refreshingly titled “Low Back Pain and Posture” (Tuzun, Yorulmaz, Cindas, & Vatan, 1999) grouped subjects into acute pain, chronic pain, and a pain-free control groups of 50 each, then measured their degrees of thoracic kyphosis, lumbar lordosis, and sacral inclination in a relaxed standing posture with no shoes. Some correlations were found between age and thoracic kyphosis, and between BMI and lumbar lordosis. However, when comparing these postural angles between the subject groups, the researchers detected no statistically significant differences. In their conclusion, the researchers state that it is not reasonable to make a generalization regarding these angles and low back pain.

            This is not to say, however, that the two are unrelated. Three possible explanations were offered by Christie, Kumar, and Warren, who were mentioned above. They found that those in acute pain were more likely to have greater thoracic kyphosis and forward head positions, and that chronic back pain sufferers showed significantly greater lumbar lordosis. The postural parameters they studied only had moderate value in the prediction of pain, and they would not state whether posture lead to pain or precipitation of pain causes postural aberrations. Instead, they offer three possible explanations for the correlations they found:

1.With the onset of pain, all aspects of the spinal curve initially respond to the pain with increased forward head posture to decrease lumbar pain

2. Individuals with acute low back pain may have had a preexisting FHP that resulted in flexion of the T spine and signs and symptoms in the lumbar spine

3. Chronic LBP sufferers have adapted to the pain with a localization of the postural changes the lumbar spine that balances the upper spine back towards normal.

            The lack of consensus in these studies are probably due to the fact that methodologies for measuring posture, pain, or both varied significantly between one study and the next. For example, our two studies on adolescents came to different conclusions: one took a relatively simple measurement of posture, administered a simple yes/no questionnaire on lifetime back pain, and got no correlation (Ozyurek, Genc, Karaali, & Algun, 2017); the other took a more detailed questionnaire inquiring into different types of pain and correlated that with specific postures, separated further by male and female, and got the more nuanced results discussed earlier (Smith, O'Sullivan, & Straker, 2008). Perhaps both “posture” and “low back pain” are simply not specific enough terms on their own to ensure consistent definitions and methodologies across a broad range of studies. As Christie et al put it, “Ideal posture has not been universally agreed to and several different definitions have been advanced.” However, classifications of ‘neutral’, ‘hyperlordotic’, ‘flat’, and ‘sway’ have been used by several authors in several studies: O'Sullivan, et al., 2002, Smith, O'Sullivan, & Straker, 2008, and Christie, Kumar, & Warren, 1995, so perhaps there is still enough consistency to make useful comparisons.

­Longitudinal Studies on Posture and Low Back Pain

            Longitudinal experiments are widely considered to be the gold standard at establishing cause and effect in a population. However, the time and monetary commitment they require make them more prohibitive than observational studies. The following two studies took a baseline measurement of a subject pool, then followed those same subjects over a period of time to see the long-term impacts, if any, of a multitude of factors, including posture.

            Widhe, 2001 measured the thoracic kyphosis, lumbar lordosis, spinal mobility, and incidences of back pain in a group of 90 children at ages 5 and 6, and then again at ages 15 and 16. He found that posture did change significantly during the study period: both thoracic kyphosis and lumbar lordosis increased by roughly 6°, and gender differences that were not present at ages 5-6 presented themselves at age 15-16. He also found that mobility significantly decreased during the 10 years between measurements, particularly in the thoracic spine. Finally, he reported that about one-third of the children at 15-16 stated that they had occasional low back, which was similar to other reports using comparable methods. However, these incidences of low back pain were not related to posture, spinal mobility, or even physical activity in the sample population he took.

            Widhe offers some insights into his findings. He suggests that the sharp rise in the prevalence of low back pain between pre-pubescence and puberty could reflect the transition from “living in the present” to “bodily awareness”; the pain may not be a pathological condition of the spine itself, but a new dimension of the mind. This, he states, may explain why it has been hard to find any “physical parameters” predicting future low back pain. He also contrasts LBP in youngsters and adults, as the definition of back pain in the latter group is often defined by its consequences, such as work incapacity, as opposed to simply pain and discomfort.

            For a perspective on adults, Adams et al., 1999 followed 403 healthcare workers aged 18-40 for three years, with initial testing that included functional assessments of anthropometry, muscle strength and endurance, mobility, and posture, as well as psychological assessment via the MSPQ+ZUNG. The subjects also answered a questionnaire every 6 months to check for low back pain. The study found the following to be consistent predictors of low back pain: reduced range of lumbar lateral bending, a long back, reduced lumbar lordosis, increased psychological distress (measured by the MSPQ+ZUNG), and previous nonserious low back pain. Only the latter three were consistent predictors of “any” back pain.

            However, even in a longitudinal study, correlation still does not equal causation. The results of the study state that these factors were much better predictors of low back pain than chance alone, but even when combined (posture was only one of many factors considered predictive) the researches only obtained an R² % value of 11.6. This means that less than 12% of the volunteers studied could attribute their back pain to any of the psychological or physical risk factors considered in the study. Under the section of their article titled “What Caused Most of the Back Pain?”, the researchers wrote: “Despite these possibilities, it is becoming apparent that there are no simple explanations for LBP, only a large number of interacting causes that must be identified and pieced together like a jig-saw puzzle. As far as relatively trivial LBP is concerned, the effort to pursue these causes may simply not be worthwhile, because the failure of all the physical factors to predict “any” LBP in the current study surely indicates that mechanical influences in the reporting of such pain are negligible.”

Conclusion

            Posture is a complicated topic that, despite having a general consensus around “neutral” being better, researchers have been yet to quantify in exact terms. Low back pain is an enormously complex subject that not only has a plethora of physical factors to consider, but psychological, social, and environmental factors as well. Without a concrete understanding of the complexities of either, it is very difficult to make accurate predictions about the relationship between low back pain and posture to a large population, and harder still to apply these broad concepts in a clinical setting where possibly the only firmly established truth about either is that they are both highly individualized. It is my opinion that static standing posture has not been proven to be a reliable predictor of low back pain, and that dynamic postures and loading probably play a more significant role.

           

           

References

Adams, M., Mannion, A., & Dolan, P. (1999). Personal Risk Factors for First-Time Low Back Pain. Spine, 2497-2505.

Burnett, A., O'Sullivan, P., Ankarberg, L., Gooding, M., Nelis, R., Offermann, F., & Persson, J. (2008). Lower lumbar spine axial rotation is reduced in end-range sagittal postures when compared to a neutral spine posture. Manual Therapy, 300-306.

Cadar, I., & Pop, L. (2015). Correlations between cervical spine posture and low back pain. Human & Veterinary Medicine, 178-181.

Christie, H., Kumar, S., & Warren, S. (1995). Postural Aberrations in Low Back Pain. Archives of Physical Medicine and Rehabilitation, 218-224.

Chung, S., Lee, C., Kim, S., Chung, M., & Ahn, J. (2000). Effect of low back posure on the morphology of the spinal canal. Skeletal Radiology, 217-223.

Claeys, K., Brumagne, S., Deklerck, J., Vanderhaeghen, J., & Dankaerts, W. (2016). Sagittal evaluation of usual standing and sitting spinal posture. Journal of Bodywork and Movement Therapies, 326-333.

Hoy, D., Bain, C., Williams, G., March, L., Brooks, P. B., Woolf, A., . . . Buchbinder, R. (2012). A Systematic Review of the Global Prevalence of Low Back Pain. Arthritis & Rheumatism, 2028-2037.

Jackson, R., & McManus, A. (1994). Radiographic Analysis of Sagittal Plance Alignment and Balance in Standing Volunteers and Patients with Low Back Pain Matched for Age, Sex, and Size. Spine, 1611-1618.

O'Sullivan, P., Grahamslaw, K., Kendell, M., Lapenskie, S., Moller, N., & Richards, K. (2002). The Effect of Different Standing and Sitting Postures on Trunk Muscle Activity in a Pain-Free Population. Spine, 1238-1244.

Ozyurek, S., Genc, A., Karaali, H., & Algun, Z. (2017). Three-dimensional evaluation of pelvic posture in adolescents with and without a history of low back pain. Turkish Journal of Medical Sciences, 1885-1893.

Pillastrini, P., Mugnai, R., Bertozzi, L., Costi, S., Curti, S., Guccione, A., . . . Violante, F. (2010). Effectiveness of an ergonomic intervention on work-related posture and low back pain in video display terminal operators: A 3 year cross-over trial. Applied Ergonomics, 136-443.

Smith, A., O'Sullivan, P., & Straker, L. (2008). Classifcaton of Sagittal Thoraco-Lumbo-Pelvic Alignment of the Adolescent Spine in Standing and Its Relationship to Low Back Pain. Spine, 2101-2107.

Tuzun, C., Yorulmaz, L., Cindas, A., & Vatan, S. (1999). Low Back Pain and Posture. Clinical Rheumatology, 308-312.

Widhe, T. (2001). Spine: Posture, mobility and pain. A longitudinal study from childhood to adolescence. European Spine Journal, 188-123.

Poor Shoulder External-to-Internal Strength Ratios Found to Increase Injury Risk in Overhead Athletes and Their Applicability to Recreational Weight Training Populations

Justin Gibson, BS, CSCS

Introduction

Shoulder performance and injury is a major topic of interest for professional athletes, recreational fitness enthusiasts, and the general population alike. Whether discussing one’s ability to throw a baseball at a consistently high velocity or their ability to hoist a gallon of milk onto a countertop, the strength and health of the glenohumeral joint should and has been the subject of a large body of scientific literature. However, when seeking funding for a research proposal, it is perhaps easier to justify studying a shoulder when it is attached to a body on a $3.1 million dollar 2-year contract than it would be if it were attached to someone lifting weights as a hobby. And so, a large proportion of our scientific literature regarding the shoulder tends to focus on athletes, specifically overhead athletes, when attempting to identify potential risk factors for injury.

          One such risk factor explored in these studies has been the balance between external rotation strength of the shoulder and internal rotation strength. For overhead athletes in particular, it is believed that the eccentric strength of the external rotators should be as strong as the concentric strength of the internal rotators to maintain glenohumeral stability and optimal shoulder function (Wang & Cochrane, 2001). In this paper, I will discuss the scientific evidence linking internal/external rotator imbalance as a predictor of injury in overhead athletes, the similarities between these athletes and recreational weightlifters, and possible data that may build a bridge between them.

External/Internal Rotation Strength Ratios as a Predictor for Injury in Overhead Athletes

          Several studies have noted a link between shoulder muscle imbalance and injury. Two such studies looked at several factors that may contribute to shoulder injury: range of motion, external rotation weakness, scapular asymmetry, and ER/IR strength ratios. Clarsen, Bahr, Anderson, Munk, & Myklebust (2014) measured all of these factors when following the teams in the Norwegian elite handball series for men for three months of the 2011-2012 season. They found significant associations between ER weakness, obvious scapular dyskinesis, and shoulder range of motion, and inury, and “noteworthy” associations between injury and ER/IR strength ratios. To directly quote the study, “non-significant trends in the data suggest that lower ER to IR ratios and abduction strength may also be noteworthy risk factors.”

 In contrast, Wang & Cochrane (2001), in their study on elite male volleyball players, concluded that shoulder rotator muscle strength imbalance (eccentric external/concentric internal <1) played in statistically significant role in the shoulder injuries of their athletes over the course of their season, whereas shoulder mobility, scapular asymmetry, and muscle strength were not significantly associated with injury.  These two studies each have their merits and limitations: The Clarsen study follows a larger group of athletes, while the Wang study measures a longer timeframe. Both studies, however, at least make note of the ER/IR ratios as a risk factor, and both studies extensively reference other studies done on overhead athletes when discussing possible causes of injury.

          Perhaps stronger evidence for the link between ER/IR imbalance and injury is seen in Bryam, et al. (2010). While the researchers’ hypothesis mainly concerned the weakness of shoulder external rotators (which they found to be very strongly associated with injury), they also found significant links between low ER/IR strength and overall throwing injuries and an even stronger association with shoulder injuries specifically. This study was conducted over a 5 year period at looked at 144 Major and Minor League Baseball pitchers, a much larger scope than the previous two studies (and with, as noted earlier, more expensive subjects).

          All three of these studies discuss, independent of their findings, why a proper ER/IR strength ratio may be important in predicting injury. Handball, volleyball, and baseball all involve motions that require significant internal rotation torque to perform at a high level, and as a result, these athletes tend to develop very strong internal rotators without a concurrent strengthening of their external rotators (Codine, L., Pocholle, Benaim, & Brun, 1997). In a high-velocity activity such as throwing, this imbalance may lead to soft tissue injuries as the weak external rotators are unable to provide enough stability to the glenohumeral joint to counteract the immense forces produced by the internal rotators. With this in mind, are these findings relevant to the average weight lifter, or do they only apply to the specific motions of overhead athletes?

The Role of the Rotator Cuff in Glenohumeral Stability and Movement

          Thus far this paper has not attributed internal or external rotation to any specific muscle or muscle group, but of course these motions are achieved by the contraction of specific muscles. Most anatomy textbooks attribute internal rotation to the subscapularis of the rotator cuff, with the larger pectoralis major, anterior deltoid, and latissimus dorsi muscles contributing significantly. The posterior muscles of the rotator cuff, the infraspinatus and the teres minor, are the external rotators, with only the posterior deltoid providing significant additional force, although some studies also suggest the supraspinatus could play a significant role (Dark, Ginn, & Halaki, 2007). This difference in cross-sectional area of muscles that provide internal rotation vs. external rotation could explain why even in non-athletes, internal rotation strength is significantly higher (Noffal, 2003).

          Rotation, however, is not the only function of the rotator cuff. It could be argued that their isometric role in stabilizing the humeral head in the glenoid fossa is as or more important than their isotonic role in providing rotation. Centering the axis of rotation in the glenohumeral joint could be an important factor in preventing shoulder impingement, and it is a role for which the rotator cuff muscles, particularly the inferior and posterior components, are well suited (Sharkey & Marder, 1995). Indeed, instability of the shoulder joint has been shown to be a major predictor of injury in overhead athletes and weightlifters (Gross, Brenner, Esformes, & Sonzogni, 1993).

Applying ER/IR Strength Ratios to the Weight Training Population

          Now that we have established some evidence that a lack of external rotation strength compared to internal rotation strength has been observed to predict injury in overhead athletes, and that specific muscles are responsible for these actions, we can begin attempting to link this information to the recreationally trained weight lifting population. Some common ground has been found between the ER/IR strength ratios of throwers and recreational weight lifters. When comparing throwers to non-throwers, Codine, L. et al (1997) and Noffal (2003) found that throwers had a lower concentric ER/IR strength ratio (about 0.57 and 0.65 at 300 degrees/second, respectively) than non-throwers (about 0.75 at 300 degrees/second in both studies) in their dominant throwing arms, and that this was due to the throwers’ higher IR strength without a significant increase of ER strength over non-throwers.

A similar study which looked at muscluar strength differences between the recreational weight training population and a control group found that these same ER/IR strength discrepencies also exist in the recreational weight training population (about 0.61), and that this imbalance is also due to a strengthening of the internal rotators without concurrent strengthening of the external rotators (Kolber, Beekhuizen, Cheng, & Hellman, 2009). In EMG studies, the pectoralis major, commonly targeted in traditional weight training programs, has been shown to contribute significantly to internal rotation (achieving similar activation rates as the subscapularis), whereas no such large muscle is activated nearly to the same extent as the infraspinatus during external activation (Dark et al, 2007).

          Shoulder instability, particularly anterior shoulder instability, has been observed in weight lifters with shoulder pain. Gross, et al (1993) observed that every patient in their study (all of whom had recurrent instability in one or both shoulders and reported weight lifting as their primary recreational activity) experienced pain in abducted and externally rotated positions when the humeral head is translated anteriorly in the glenoid fossa, and that most of them could not recall any particular event that caused the pain.  In common weight training exercises such as the bench press and row, the rotator cuff functions in a reciprocal fashion to oppose translation of the humeral head by the larger external muscles acting on the shoulder; the infraspinatus is highly active during the bench press to oppose the pectoralis major’s anterior pull, and the subscapularis is highly active during the row to oppose the latissimus dorsi’s posterior pull (Wattanaprakornkul, Halaki, Cathers, & Ginn, 2011). However, as noted in the Kolber study, there is little evidence to suggest that the infraspinatus is significantly strengthened alongside the larger pectoralis major in most common resistance training programs. This may provide a possible explanation as to why some recreational weight lifters experience progressive shoulder pain: large muscles such as the pectoralis major are strengthened at much faster rates and have a much larger total strength capacity than the muscles of the posterior rotator cuff, and eventually these smaller intrinsic muscles cannot adequately stabilize the glenohumeral joint during exercises like the bench press.

Shoulder Injury Prevention in Weight Training Populations and the Case for More Research

          Although not common in traditional weight training programs, the infraspinatus and other rotator cuff muscles can be specifically targeted and relatively isolated from other muscles with the right exercises (Escamilla, Yamashiro, Paulos, & Andrews, 2009). Properly designed strength training programs that include exercises to specifically target external rotators can limit or eliminate the ER/IR strength discrepancy found to be common in weight lifters (Niederbracht, Shim, Sloniger, Paternostro-Bayles, & Short, 2008).

          It is important, however, to note that the comparison between throwing athletes, recreational weight lifters, and the methods used to measure their respective muscle imbalances, has several caveats and outright flaws that need to be addressed. Testing methods for ER/IR rotation varied across the studies I’ve presented in this paper; Bryam (2010), Clarsen (2014), and Kolber (2009) all used isometric testing protocols to measure ER/IR strength, whereas Wang (2001), Codine (1997), Noffal (2003) used isokinetic testing. This is important to note because the sports played by the athletes in the study involve dynamic, rather than isometric, motions of the shoulder, often under immense load and stress. Baker, Wilson, & Carlyon (1994) found that while isometric and dynamic measurements of strength are significantly related, they were not so closely related to imply generality of muscle strength across all contraction types and speeds. It would not be advisable to assume that isometric strength is always going to predict high-velocity eccentric strength, or that changes in isometric strength over the course of a strength training program always reflect dynamic changes in strength.

          Isometric testing, however, may be appropriate for testing the strength of the infraspinatus in recreational weight lifters. As previously stated by Wattanaprakornkul (2011), the infraspinatus plays a major isometric role in glenohumeral joint centration during the bench press as it opposes anterior translation, which contributes to anterior instability. I would make the case that measuring the isometric ER/IR strength ratios of recreational weight lifters might be an effective estimate their posterior rotator cuff’s ability to maintain glenohumeral stability against the pull of the pectoralis major during popular exercises like the bench press. Studies referred to in this paper have only looked at these ER/IR strength imbalances as they relate to overhead athletes, and further study would be recommended to see if such a correlation exists in the recreational weight training population.

Conclusion

The connection between low external-to-internal rotation strength of the shoulder and risk of injury has been well documented in throwing and overhead athletes, and the need to maintain proper balance between the two has been the objective of many strength and conditioning programs for athletes of all levels. Low ER/IR strength ratios similar to that of overhead athletes have also been observed in recreational weight lifters. Considering the dual role of the rotator cuff as shoulder rotators and shoulder stabilizers, and that traditional strength training tends to neglect the external rotators, more research needs to be done to determine whether this same ER/IR strength discrepancy when present in weight lifters carries the same risk of injury.

         

         

Bibliography

Baker, D., Wilson, G., & Carlyon, &. B. (1994). Generality versus specificity: A comparison of dynamic and isometric measures of strength and speed-strength. European Journal of Applied Physiology, 350-355.

Bryam, I. R., Bushnesll, B. D., Dugger, K., Charron, K., Harrell, F. E., & & Noonan, T. J. (2010). Presason Shoulder Strength Measurements in Professional Baseball Pitchers. The American Journal of Sports Medicine, 1375-1382.

Clarsen, B., Bahr, R., Anderson, S. H., Munk, R., & & Myklebust, G. (2014). Reduced Glenohumeral Rotation, External Rotation Weakness and Scapular Dyskinesis Are Risk Factors for Shoulder Injuries Among Elite Male Handball Players: A Prospective Cohort Study. Br J Sports Med.

Codine, P., L., B. P., Pocholle, M., Benaim, C., & Brun, V. I. (1997). Influence of Sports Discipline on Shoulder Rotator Cuff Balance. Medicine and Science in Sports and Exercise, 1400-1405.

Dark, A., Ginn, K. A., & Halaki, M. (2007). Shoulder Muscle Recruitment Patterns During Commonly Used Rotator Cuff Exercises: An Electromyographic Study. Physical Therapy, 1039-1046.

Escamilla, R. F., Yamashiro, K., Paulos, L., & & Andrews, J. R. (2009). Shoulder Muscle Activity and Function in Common Shoulder Rehabilitation Exercises. Sports Medicine, 663-685.

Gross, M. L., Brenner, S. L., Esformes, I., & & Sonzogni, J. J. (1993). Anterior Shoulder Stability in Weight Lifters. The American Journal of sports Medicine, 599-603.

Kolber, M., Beekhuizen, K., Cheng, M., & & Hellman, M. (2009). Shoulder Joint and Muscle Characteristics in the Recreational Weight Training Population. Journal of Strength and Conditioning Research, 148-157.

Niederbracht, Y., Shim, A. L., Sloniger, M. A., Paternostro-Bayles, M., & & Short, T. (2008). Effects of a Shoulder Injury Prevention Strength Training Program on Eccentric External Rotator Muscle Strength and Glenohumeral Joint Imbalance in Female Overhead Activity Athletes. Journal of Strength and Conditioning Research, 140-145.

Noffal, G. (2003). Isokinetic Eccentric-to-Concentric Strength Ratios of the Shoulder Rotator Muscles in Throwers and Non-Throwers. The American Journal of Sports Medicine, 537-541.

Sharkey, N. A., & Marder, R. A. (1995). The Rotator Cuff Opposes Superior Translation of the Humeral Head. The American Journal of Sports Medicine, 270-275.

Wang, H.-K., & Cochrane, T. (2001). Mobility impairment, muscle imbalance, muscle weakness, scapular asymmetry and shoulder injury in elite volleyball athletes. The Journal of Sports Medicine and Physical Fitness, 403-410.

Wattanaprakornkul, D., Halaki, M., Cathers, I., & & Ginn, K. A. (2011). Diretion-Specific Recruitment of Rotator Cuff Muscles During Bench Press and Row. Journal of Electromyography and Kinesiology, 1041-1049.

Boring But Big

Odds are that if you've been in close proximity to iron bars and cutoff shirts for any real length of time, you've heard about 5/3/1, the training program developed by monster-truck-that-walks-like-a-man Jim Wendler.

If you haven't, well, now you have.

This is a strength program developed for people who want to get stronger. If that statement seems redundant, a quick glance through one of Wendler's books will tell you that this man is nothing if not direct. No frills, no "functional" training, no imbalance correction, and no equipment that comes in colors other than gray or black. He is a meathead worthy of the title, and while he doesn't go so far as to throw decades of lifting science out the window, he insists that the only measure that matters in the gym is the weight on the bar.

Though seven years of gym experience that encompass a Bachelor's degree in Kinesiology and two training certifications, I feel I am qualified to agree that, scientifically, you should indeed lift weights in an effort to get stronger. So, you know, he has science to back him up.

I haven't had a goal to train for since competing in my first -and only- bodybuilding competition back during my Sophomore year at the University of Kentucky, so my training has been without constant direction for some time now. Like many lifters, I'd go through spurts of different programs. I did Crossfit for a year, and when my elbows stopped working I get really into the corrective exercises of rehab and prehab (go figure), then I went back to bodybuilding for size, then I decided I should have a six-pack year round (HA.), then I got into Olympic lifting....

You can see where this is going. Month after month, year after year of looking the same and being slightly more improved at whatever I was doing at the time but no stronger in anything else.

The one thing that has steadily improved over my years of program hopping has been my deadlift, due entirely to my love affair with it. Seriously, I love me some deadlift. When my deadlift hit 450 for the first time, I entertained the notion of entering a powerlifting competition, momentarily forgetting that you also have to be good at the squat and bench press and also 450 is not that impressive. Maybe I just missed that competitive drive, or maybe I just really wanted to wear a singlet, but I now have my sights set on the Georgetown Classic  as a raw full powerlifter in the 181 lb class.

Pictured: Style.

So after I finished my 10,000 kettlebell swings (really oughta post something about how that went...you know, like I said I would. Good, for the record), I needed to bulk up. At 167 lbs, I had plenty of room to go to remain in my 181 lb class. Which, finally brings me back to the 5/3/1 program.

5/3/1 is fairly simple. Your main lifts are the press, the deadlift, the bench press, and the squat. You work these lifts on separate days of the week using preset percentages based off of your training max. Your training max is defined by 90% of your best current one rep max in the gym.

Week one has you doing three sets of 5 reps at 65%, 75%, and 85% of your training max on your lift for that day.

Week two has you doing three sets of 3 reps at 70%, 80% and 90% of your training max.

Week three has you doing 5 reps at 75%, 3 reps at 85%, and 1 rep at 95%.

After this three week cycle, you add 5 lbs to your training max for your upper body lifts (the press and the bench press) and 10 lbs to your training max for your lower body lifts (your deadlift and squat).

There is a swarm of different variations and concepts, but that is the gist of the program. If you want more information, please support Jim buy actually buying the 5/3/1 training manual. His four basic principles, in particular, are fantastic, and I'd feel like I was blatantly stealing them by posting them here.

To gain some much-needed size (big muscles are strong muscles, after all), I decided to go with a hypertrophy variation of the 5/3/1 program called "Boring But Big".

In the past, "bulking" has usually consisted of me changing nothing about my training and just eating a lot. I get fat, then I hate feeling fat, than I diet off the fat and I'm back where I started with very little to show for it.

From the start, I had two advantages. The first was the 181 lb weight limit on my chosen class. I know that if I go over that limit and have to compete in the 198 lb class, I will be crushed, perhaps literally. The other is the nature of the program: high volume with slowly heavier weights.

I'm telling you all of this because I started it back in November, and it's been by far the most successful bulk I've ever done.

Disclaimer: I cheated. I didn't do the program 100% as written, because my ego thinks I know better than someone three times stronger and with decades more experience than me. My ego is dumb. Still, it sure did work.

The concept behind the program is simple. The 5/3/1 sets of the big lifts will keep you strong. To get big, though, you need lots of volume. This variation has you doing 5 sets of 10 reps of the bench press after your strength work on your press day (and vice versa) and 5 sets of 10 reps of the squat after your deadlifting strength sets (and vice versa. Yes, 5 sets of 10 deadlifts on your squat day. Yes it is awful.)

So where do you start on those five sets of ten? Easy: 50% of your training max.

DO NOT UNDERESTIMATE THIS. When you load up the bar with essentially 45% of your one rep max, it seems like a joke, or at the very least a warm-up set before you put the real weight on. I'll admit that my first week had me doing 5 sets of 10 reps on the bench press with 105 lbs. You read that right: an aspiring powerlifter doing 105 lbs. Most beginners start with more than that. It was humiliating, and as I was doing it I hoped people though I was coming back from an injury of some sort, like maybe I had my arms recently re-attached after a horrible farming accident. The weight felt like nothing, even when trying to throw it at the ceiling, and even after all five sets.

The next day I was so sore I could barely move my hands closer together. 50 reps is a lot, even with a "light" weight. Start light and add 5 lbs per week to your press and bench press, and 10 lbs per week to your deadlift and squat for your 5x10 sets. Going up slowly and steadily like this means at the end of the program, your volume for your squat and deadlift go up by 4500 lbs (90 extra pounds over the course of 50 reps) and your upper body pressing volume goes up by 2250 lbs (45 extra pounds over the course of 50 reps). That's a big improvement.

The last thing I'll say regarding this bulking program: Eat. Eat like you're not afraid to gain weight. Weight gainers, whole milk, jars upon jars of peanut butter; any high-calorie food that isn't junk should be going down your gullet in sizable proportions.

The Program

This is a nine week program that has you working out 4 days per week. It is structured as follows:

(note, exercises and stretches under main lifts are meant to be done in a superset fashion, alternating between the two)

Monday:

-Press: 5/3/1 sets and reps

   -Pulling exercise x 10 reps between sets (chins, rows, pullaparts, etc)

-Bench Press: 5 sets of 10 at 50% of TM (add 5 lbs next week)

   -Chin ups or pulldowns: 5 sets of 10 with moderate load

-Optional 3 sets of ten for biceps, triceps, and upper back

Tuesday:

-Deadlift: 5/3/1 sets and reps

   -Stretch hip flexors

-Squat: 5 sets of 10 reps at 50% of TM (add 10 lbs next week)

   -Ab work, 5 sets of 10 reps

Thursday:

-Bench press: 5/3/1 sets and reps

   -Wide grip pullups/pulldowns, x10

-Press: 5 sets of 10 reps at 50% of TM (add 5 lbs next week)

   -Dumbbell row: 5 sets of 10 reps at moderate load

-Optional 3 sets of ten for biceps, triceps, and upper back

Friday

-Squat: 5/3/1 sets and reps

   -Stretch hip flexors

-Deadlift: 5 sets of 10 reps at 50% of TM (add 10 lbs next week)

   -Ab work: 5 sets of 10 reps, optional crying

There you have it. By the end of this program I was much bigger and much stronger, going from benching 105 for my volume work to benching 155 (if you can do simple addition, you may notice I got ambitious one week and added 10 lbs instead of five. Ego, again, gets in the way.) My chest is much bigger, my arms are bigger (even bigger than when I finished by direct arm training program a year ago), and my squat is much, much better. This isn't some theoretical concept of bulking here; I did this. This exact thing. And it worked. It worked so well, I've put several of my clients on a similar program.

If you do it right, it will work for you too.   

Starting Week 2, and Also Deadlifts

First, check out my awesome client Ed as he kills some heavy deadlifts:



Yeah, he's a beast.

Also, I'm 3,000 swings into my 10,000 kettlebell swing challenge, and it's going fairly well. Down about 1% bodyfat and about 4 pounds.

I've lost some noticeable fat, my abs are just a bit more visible, and my bike ride to work on Thursday (typically a miserable exercise in self-punishment) wasn't nearly as tiring as it usually is.

The diet, which again you can read about here, has been pretty easy to stick with so far. I'll be honest and say I haven't stuck to the plan 100%, but most of my meals are still the protein shake + fruit or vegetable + peanut butter, but I've added in a sensible meal for dinner and/or breakfast in place of the first or last protein shake. Calories are the same, and maybe it's because I've been super busy at work recently but I haven't been half as hungry as I thought I'd be. The added protein is also doing good things to keep some muscle on my frame, and....dare I say it...may have even added a bit.

The workouts, too, are getting easier. My hands are a bit torn up, but aside from a bit of hamstring soreness once or twice, I feel pretty good. My pace has increased considerably, and now even the sets of 50 are over before I know it, sometimes literally! I've lost count a few times during the higher reps, which brings me to the only negative aspect of this program I've encountered: the monotony. 10,000 of anything is going to get pretty boring, and I still have 7,000 to go.

7,000 to go.

Simple Fat Loss: a 4-Week Experiment

I like it when things are simple. Simple things make me happy, and I like to be happy.

So when I looked at my kettlebell swing form in the mirror after getting out of the shower (don't try to form too clear a picture in your head, and definitely don't ask why) and saw things jiggle that ought not to jiggle, I decided it was time to drop some body fat.

Not lose weight, mind you. You can chop off an arm and lose weight. I still want to be strong(ish) and I still want to look like I'm strong(ish), and that requires holding on to or even gaining muscle mass. That means staying far away from any starvation-based, macro-nutrient demonizing, Hollywood bimbo-endorsed "diet cleanse" that leaves you hungry and weak and requires you measure every seed in your tiny serving of watermelon so as not to go over your allotted food mass limit of the week.

For my fat-loss program to work, I need four things:

-Plenty of protein to maintain muscle mass
-A caloric deficit large enough to be effective but small enough to stay away from starvation mode
-Plenty of vitamins, minerals, and fiber to keep me feeling good and healthy
-Some leeway to account for having a life outside of dieting.

This last one is what I thing breaks most people. In a bubble, I think most people have the willpower to see even a super-strict diet to its conclusion and see great results. But life...just, like, frickin' life man, it just gets in the way. Work gets overwhelming, your significant other wrecks your car, 30 Rock has its final season, and when your buddies invite you out to the bar Saturday night you just want to unwind and have like six plates of wings and a beer for each one and not have to explain why you're on a diet and only ordered water.

The other half of the equation is what happens in the gym. Nineteen protein shakes a day won't help you hold on to your precious muscle mass if you don't give said muscles a reason to exist. I firmly believe you should keep lifting heavy while dieting, and seek to at least maintain your strength levels while throwing in some conditioning work to burn more calories and increase your work capacity.

Here's the thing though: I hate training when I'm on a diet. My willpower is usually so sapped from denying myself food that I can't pony up the man juice to do that last set of heavy front squats. As a result, my workouts suffer and I don't do enough to elicit a training effect to hold onto what little mass I've worked so hard to get.

I need three things from a training program:

-Simplicity. I don't want to write an extravagant workout-to-end-all-workouts every time I lift, I just want to train and go home. Or more accurately, back to work, seeing as how I work in a gym.
-Rigidity. I need a plan on paper that I'm not allowed to deviate from, and that I must complete before I'm done.
-Intensity...sort of. I need weights that keep me strong without breaking me, and conditioning work that gasses me without obliterating me.

With that, and with not just a little inspiration from T-Nation, I've developed a four-week fat loss plan that is simple and has everything I require.

Nutrition

My diet, every single day, is:

Breakfast
1 cup oatmeal
1 scoop vanilla protein powder
1 tbs peanut butter

Meal 2
1.5 scoops protein powder
1 tbs peanut butter
1 serving of fruit

Meal 3
1.5 scoops protein powder
1 tbs peanut butter
1 serving of fruit

Meal 4
1.5 scoops protein powder
1 serving of canned vegetables

Meal 5
1.5 scoops of protein powder
1 serving of canned vegetables

Total Calories: ~1800
Protein: ~ 180 grams
Calories required for defecit: 2200

See that last part? I have 400 calories not included in my meal plan. Those go wherever, however I want them. Two slices of pizza at night? Go for it.  A couple of brownies my roommate cooked up? Sure! Even -gasp- a beer or two after work? CRAZY! IRRESPONSIBLE! ....and allowed.

I try to eat a lot of colors and add spices here and there to make things bearable, but that's the entirety of my meal plan.

Training

Even simpler. The 10,000 Swing Kettlebell Workout, as prescribed by Dan John:

http://www.t-nation.com/workouts/10000-swing-kettlebell-workout

I chose this one for two reasons:

1. Dan John wrote it

2. See number 1

Okay, a little more reasoning:

I am a big fan of kettlebell swings for conditioning. They gas you pretty quickly, they're easy to learn, and they work my favorite muscle group, the glutes. The workout also intersperses heavy strength movements into the mix, which I really like. 

It's also tough, but doable. My first workout left me sweating like I haven't in months, but I didn't have the burning in my throat and the dizzying fatigue I remember from my Crossfit days. And something about the workout just...I don't know, felt right. 

Starting video and photos

Here's a video of my fourth round of the workout:

http://www.youtube.com/watch?v=mze_bMBd0jk

And here are my starting photos:

I will try to update often, post about my progress and, above all, see this little experiment through to the end.

Writing Your Success Story: Strength

We all have our reasons for going to the gym. Or at least we have reasons why we know we should go to the gym. You might even go through the process of writing down a specific, attainable goal that you consistently work towards.

 But how do you know if you've made any headway?

If you're going to write your own personal success story, you need definitive proof for yourself and all those who care to know that you've moved away from where you were and closer to where you want to be. This next series of posts will be about what you should be measuring in the gym to keep track of your progress and how you can go about it.

Hint: your goal should look a lot like this. Including the beard. Yes, you too ladies.

Goal: Get Stronger

It's a small wonder that even in 2013, where a strong back doesn't have nearly as many career advancement opportunities as a strong background in database management, strength is still a hugely valued attribute. What's even more surprising -and awesome, in my opinion- is that it's not just limited to rage-fueled jocks anymore; geeks, girls and geeky girls are finally inching their way into the iron game and finding their place under heavy weights.

But it's not enough to just show up at the gym and grunt, though grunting will account for most of your success.

Attained by: getting stronger in three big lifts, over the course of three months. 

Pick three big, multi-joint lifts, and try to improve your numbers in these lifts over the course of three months. Pick whatever three you want, but follow these guidlines:

-You should pick lifts that cover your entire body

-You should be comfortable with and have excellent form on these lifts

-You should pick a rep number to quantify your improvement. Said better, you should decide if you want to improve your 1 rep max, your 2 rep max, your 5 rep max, etc. I personally dislike 1RM's because they encourage bad form and are heavily influenced by outside factors; I like 3 reps, because ego is less of a factor and you'll get more training stimulus by keeping the reps slightly higher.

Here are some ideas for your big three exercises:

Back Squat, Deadlift, and Bench Press

The classic powerlifting combo is popular for a reason. A bit low-back intensive, but with the added possibility of getting involved in a growing sport.

Bench Press, Chin Up, and Front Squat

This is a great combo for anyone whose back can't handle frequent back squats and deadlifts.

If physique is a secondary goal, you should aim to be really good at chin-ups. If you're getting better at chins, it's either because you're stronger or leaner or both. I have this theory that for as long as you can do 10 honest, all-the-way-down, all-the-way up chin ups, you'll never be out of shape. And if you can do 3 chin-ups with 100 lbs of external load, you get your beast card in the mail within 5 business days.

Hang Power Clean, Push Press, and Bulgarian Split Squat

Are you an athlete? Whether you're on your high school football team or just play pick-up basketball every Thursday, you need two things specifically in addition to your other gym goals: power and single-leg strength. I like the hang version better than the pull off the floor, simply  because you don't get a whole lot of added power compared to the increased risk. The push press is a great way to get crazy upper-body and core strength without destroying your shoulders, and....no, really, the push gets the bar out of the "danger zone" as far as your shoulders are concerned, even when you use more weight. And the bulgarian split squat can be loaded up like few other single leg exercises.

Putting It Together

Strength is a goal that benefits with a lot of rest, so go with lifting 3-4 days a week. Here's how you would divvy it up, using the powerlifts as an example:

 3 Day Split, 3 RM Goal

Day 1

A- Back Squat: work up to a heavy triple over the course of 3-5 sets

B1- Deadlift assistance exercise (Romanian Deadlift, pull from blocks, deficit, etc.): 3 sets of 6

B2- Upper body pull:  3 sets of 8

C - Abs, your choice

Day 2

A- Bench Press: work up to a heavy triple over the couse of 3-5 sets

B1- Squat assistance exercise (Front squat, squat w/chains, overhead squat): 3 sets of 6

B2-  Glute work (hip thrust, glute bridge): 3 sets of 8

C- Abs, your choice

Day 3

A- Deadlift: work up to a heavy triple over the couse of 3-5 sets

B1- Bench assistance exercise (close grip bench, floor press, board press): 3 sets of 6

B2- Upper body pull: 3 sets of 8

C - Finisher: Max reps of Bench and Back Squat with 60% of your 3RM from this week

Stay on this program for 3 months and try to add 5 lbs to your 3 rep max every week.  Provided you're doing everything mostly right outside of the gym -eating enough calories and protein, getting enough sleep, drinking water, getting sleep, avoiding excessive alcohol consumption, sleeping for the love of God- you'll be well on your way to being a modern He-Man. Or She-Ra. 

Another Plug for the Hip Thrust

Wordplay!

So while I was on blog hiatus for the past few months, a funny thing happened: I started my new job at Body Structure, and now have a full roster of clients ranging from kids to the elderly and from healthy and strong to injured and deconditioned. It's amazing how much experience you can gain from....doing stuff.

And from working with such a diverse clientele, I've learned these things about lower body training:

1. Squats are awesome, but not everybody can do them. Some people just don't have the knee integrity or the hip and ankle flexibility or even the right body structure (though that last group is few and far between) to squat correctly. Most people do, but even then it can take weeks and even months to master the form and start using heavy weight.

It's amazing how much we've forgotten since we got out of diapers.

2. Deadlifts are awesome, but not everybody can do them. I truly believe that deadlifts, when done correctly and in moderation, are a great way to prevent back injuries, and can definitely be used as a lower back reconditiong program. But much to my dismay most of what physical therapists say is right in this regard: people with bad backs shouldn't deadlift.

Chest up...no, chest up, hips dow- you know what, you'll find out.

It saddens me greatly, but I must concede this unfortunate fact. Form is also vital for this lift to be performed safely, and much like the squat many people lack the ankle and  hip mobility to get into a good starting position. It's simple, but there is still a learning curve.

3. Hip thrusts are awesome, and everyone can do them. Seriously. The closest I've come to meeting someone who can't do a hip thrust (or at least a glute bridge) was a woman who had neck surgery and couldn't support her neck in a supine position, and even that was fixed with a simple pad.

Adding to that, there is almost no learning curve. Bar on hips, push hips up. Genius stuff.

It's almost like this motion is ingrained into our psyche. Weird.

And maybe my favorite quality of this lift: Women can be just as strong as men with this movement, or at least very close to it. There is a pretty big gender discrepancy on the squat and deadlift, but the hip thrust is an amazing equalizer. It's not uncommon to have a woman be able to hip thrust her body weight on her very first try at this exercise, even if her squat and dead aren't up to snuff.

If you haven't given it a try, please consider this exercise. Your knees will thank you, your back will thank you, and everyone following you on the sidewalk will thank you. (Your butt will look good.)

If you need more instruction, I have no business giving it to you since the absolute greatest hip thrust instructional video ever has already been created by Mark Fisher and his crew:

And if you're serious about finally working those long-neglected glutes, you can join me in doing Bret Contreras' 30 Day Thrusting Challenge (boom, phrasing).

Here's a link: http://bretcontreras.com/the-30-days-of-thrusting-challenge/

I've already done the first day, 3 sets of 20 reps with 155 lbs. Holy glute pump, Batman!