No Perfect Form in Rehab?
If you are new to exercise, and it really does not matter which kind, you most likely will be aware of the idea that there is “good” form and “bad” form. Could this idea be more complex than you initially thought?
Humans have immense variability in their skeletal structure. A good example and one you have even seen before is the pelvis. The pubis shows extensive variability with regard to height and race (13,14). Another great example is the head of your femur which identifies the proximal end of the femur. The femoral head’s shape is covered in hyaline cartilage and is two-thirds of a sphere. The head meets the femoral neck, which projects from the femoral shaft (also called the diaphysis) in a superior medial, and slightly anterior direction (up, in and forward direction). This orientation is defined by the collodiaphyseal (CD) angle, at birth this angle will be 150º from the femoral shaft and by adulthood will decrease to 120º to 130º. This variation is due to weight bearing (15).
Keeping with the hip, there is also variation in the femoral head demonstrated by the angle of torsion. This angle is formed by looking at the relationship between the axis of the femoral head and neck and the femoral condyles. A normal femur will sit somewhere between 12-15 degrees and an increase in this angle is called ante-version, while a decrease in this angle is termed retro-version. This variation is very normal but can affect individuals abilities to perform certain more extreme ranges of motion.
This is just 2 of the vast number of examples in skeletal variation between individuals and the point is with the different bodies, angles, and levers out there it is not logical to preform every exercise to a cookie cutter form. This is also before you consider a persons past injuries, experiences, or even goals.
Doing exercise that is pain free, and activating the muscle group you want to work on while enjoying the movement then should be enough for most people.
Now if you are a body builder, olympic weight lifter, elite runner, etc. there are situations this may not so rigidly apply because you need to have fairly standardized form to catch 140 kg in the bottom of a snatch, you may work toward a specific form to maximize load through a specific muscle if you are a body builder, or may work on “microloads” (as Jack Chew would put it) if you are an elite runner to become as efficient and quick as possible. Is that most people? NOPE
Common Misconceptions & Spinal Flexion
A specific movement pattern that is often criticized, seen as dangerous, demonized, and considered “bad” is spinal flexion during lifts of all kinds.
Common misconceptions often include the idea that lifting with a flexed spine will increase anterior shear forces on spinal discs which then increases the risk of injury. There is not evidence to support this and in reality the evidence actually disproves this - why have you not heard of this you ask? When research challenges long head beliefs or ideas it is not widely circulated because it does not fit with ones beliefs/bias’s.
There are some studies supporting this claim - however the studies used to support this are over 20 years old and based on cadaver (dead humans) and animal data (1,2,3,4). This type of data cannot be extrapolated to living humans spines (1).
In fact more recent studies have shown spinal positions with greater flexion can actually reduce anterior shear forces in discs (5) and some have even shown no significant differences in spinal shear forces with different lifting styles and the “weightlifting” style of lifting resulted in slightly higher shear mores than other lifting styles (6).
That being said, there is currently no evidence to show that having spinal flexion while lifting is more dangerous than lifting with a “neutral spine”.
Examples from Research
Lets, take a step back and consider the lifts that are done while consciously trying to maintain and “neutral spine” and look at some examples:
Holder (2013) looked at this very situation and found when clients are coached to keep a neutral spine when lifting there was a minimum of 22° of lumbar flexion (8,1).
During strong man lifts there was up to 45° of lumbar flexion.
When coached to do a kettle bell swing it was found by McGill (2012) that with a neutral spine subjects had up to 26° of spinal flexion (7,1).
Finally, when coached to do the good mornings exercise and instructed to brace ‘as hard as possible’ subjects had up to 28°(1,9).
Lumbar flexion is pretty impossible to avoid regardless of technique anyway and understanding that spinal flexion is not inherently bad is important.
Now, the most common response to this is “well this can’t be true because poor form caused me injury!”. And yes, moving heavier loads in a position you are unprepared to move them in will injure you. But this is most often due to the individual being unprepared to move that load in that movement pattern rather than the movement pattern itself.
Steffans et al (2015) found lifting things awkwardly is a well known risk factor for back pain and many jobs that involve heavy lifting are associated with high levels of back pain (11,1). So what is causing such high levels of pain if it is not the way we lift?
Research shows us all pain in multifactorial and is affected by more than one aspect of our lives. However, this appears especially true with back pain, and back pain at work is more due to poor exercise tolerance, low job satisfaction, mental health issues, and other health issues than the way you are actually doing the lifting (12,1).
What would you expect would happen if you do not train for the lifts your doing at work or in the gym? or what do you expect when you train one pattern increasing load then all of a sudden switch up? All injuries are due to a combination of factors and never will be solely due to a posture, position, and style of exercise (1).
It is important to remember that when I am discussing form - I am discussing it in the context of physiotherapy and rehab. I understand there are a variety of forms to bias certain parts of muscles, muscle groups, etc which may be advantageous to an individual or athlete. Additionally, preforming exercises in their traditional forms is not a bad thing. The point of this article to create a more critical view of the exercises, forms you are doing in order to improve. As a physio I often try to let the activation felt lead the exercise rather than get too picky on form especially during rehab phases.
A big shout out to Adam Meakins for getting me thinking about these topics, helping me to become a more critical and better physio. Please keep in mind the topics I referenced with a 1 are taken from Adam Meakins various resources and definetley deserves to be checked out as well! See resources below!
1. Adam Meakins (https://www.thesports.physio)
2. Yingling & McGill (1999) Spine, 18:1882-9
3. Callaghan & McGilll (2001) Spine, 1:28-37
4.Tanaka et al (2001) Spine J, 1:47-56
5. Arjmand et al (2005) Spine, 23:2637-2648
6. Kingma et al (2010) Ergonomics, 10:1228-38
7. McGill et al (2012) Strength Cond Res, 1:16-27
8. Holder (2013) AUT Thesis open repository.aut.ac.nz/
9. Vigostsky et al (2015) PeerJ, 3e708
10. Steffans et al (2015) Arthritis Care, 3:405-10
11. Swain et al (2020) J Biomechs, 102;109-312
12. Parrerira et al (2018) Spine K, 9:1715-21
13. Ridgeway BM, Arias BE, Barber MD. Variation of theobturator foramen and pubic arch of the female bonypelvis. Am J Obstet Gynecol. 2008;198(5):546.e1-4
14. Handa VL, Lockhart ME, Fielding JR, et al. Racial differences in pelvic anatomy by magnetic resonance imaging. Obstet Gynecol. 2008;111(4):914-920
15. Maruyama M, Feinberg JR, Capello WN, D’Antonio JA. The Frank Stinchfield Award: morphologic features of the acetabulum and femur: anteversion angle and implant positioning. Clin Orthop. 2001;(393):52-65.
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