As physical therapists, we are very well trained in movement and exercise; however, much of this training comes from conventional teachings. There is a wealth of current research and opinions that are at our disposal to update and upgrade our knowledge and skills, but unfortunately, it can be difficult to distinguish the good information from misinformation.
As an example, I’ve just finished reading, for about the sixth painstaking time, a recent blog post by US soccer trainer and physical therapist Justin Shaginaw on “5 moves you should avoid at the gym.” In this post, he recommends that patients and the general public should avoid deep squats, deadlifts, overhead presses, bench presses, and anything with heavy weights. I couldn’t help shaking my head at his suggestions, as I believe these lifts (or their variations) to be an important part of the long term treatment plan for most individuals. While some of his views are purely opinion-based, others demonstrate a lack of awareness of relevant research and good exercise technique. The purpose of this article is to address each of these points and to generate discussion of these issues.
For those interested, here is the link to Mr. Shaginaw’s original post.
Here is my response to “5 moves you should avoid at the gym”. If you don’t want the research- or technique-heavy version of these topics, skip ahead to the end of the article for the implications for physiotherapists.
Outside of deadlifts, there is no other lift that has generated as much controversy as the deep squat, and as such, I will focus much of this post on squatting. It also doesn’t hurt that there’s much more research on squatting than any of the other exercises. Many physical therapists and trainers have been taught to have clients avoid squatting below 90 degrees knee flexion (shallow squat); whereas the deep squat allows the knees to flex such that the hips are below the level of the patella. There are a few myths and misinformation to deal with in regards to deep squatting:
They’re not ‘functional’
I really dislike the term ‘functional’; what really does that mean? Anything that results in better function can be called functional. A movement, exercise, or lift does not need to exactly mimic the requirements of a specific task or function to result in improvements in that task. Stopping at 90 degrees knee flexion may mimic the requirements of many activities, but the research generally shows that deeper squats actually result in enhanced performance compared to shallow squats, which suggests that they are more functional. Greater squat depth generally results in greater muscle strength, muscle size, jumping power, rate of torque development, muscle activation, and even fat loss, among other benefits [1-4]. In one of these studies, Bloomquist et al , found that deep squatting resulted in greater strength improvement of the knee extensors than shallow squatting at a more shallow knee ROM (75 degrees of knee flexion). In addition, Hartman et al  found that even though the mechanics of a vertical jump result in shallow knee angles during a jump, there was a greater transfer from deep squatting to vertical jump performance than from shallow squatting. Any arguments of ROM specificity of training should be questioned because of these findings. Deep squatting is functional and there really is not much controversy here.
They’re a recipe for: knee pain, meniscus tears ligament strain
There is more reason for controversy when it comes to knee injuries and ligamentous stress during deep squatting; although, I think we should not assume that more stress results in more problems. Mechanical stress is a potent stimulus for adaptation (see [6-7] for examples) as long as the stress is within the mechanical limits of the structure. All in all, the shear and compressive loads on the knee tendons, ligaments, and joints are well within the estimated strain capacity of healthy structures during all depths of squats . In the presence of injury, the literature is much more murky, however there is no conclusive (or even suggestive) findings that deep squatting results in injury [5,8].
Where these recommendations come from is some very old research, using very technically archaic methods of measuring joint laxity comparing weightlifters to non-lifting control participants . Subsequent research, however, has shown that a) there is no association between deep squatting and risk of injury [10-12], b) deep squatting may increase knee ligament stability , and c) deep knee flexion results in reduced ACL and PCL stresses [14-17]. It’s very interesting that these recommendations still persist.
There may be a valid argument for avoidance of deep squats in the presence of overt structurally degenerative changes to the menisci, knee joint, or patellofemoral joint. In terms of the tibiofemoral joint itself, limitations in range of motion would dictate the limits of squatting depth. Meniscal problems may be exacerbated by improper knee and hip mechanics at the bottom of the squat; however, this speaks more to the importance of good coaching than to the degree of knee flexion itself. As for the patellofemoral joint, excessive flexion may not be tolerated by some patients. Peak compressive forces, however, typically occur around 90 degrees . The highest joint forces on any lift usually occur at the transition from eccentric to concentric contractions, so stopping and reversing at 90 degrees may also be more detrimental in some trainees with a predisposition to patellofemoral pain. Add to these findings that partial squats allow for higher loads lifted, which are the most significant factor on joint and ligamentous stress, the deeper squat at a lower absolute load may be preferred in some patients even with knee pain.
While I won’t go into ‘depth’ (pun intended) on this next point, in actuality, squat depth is usually more limited by hip flexion mobility in most trainees. Limited hip flexion causes a mechanical constraint to depth while holding a neutral-ish lumbar spine and pelvis. Maximizing hip flexion can be achieved often by altering foot width and angle of turnout, but these topics can be addressed another time. Loading a lumbar spine in flexion or posterior pelvic tilt is not a good idea; which brings me to the next issue….
For the sake of limiting your reading time, I will spend less space discussing the remainder of this rebuttal, but will point you to the appropriate research or practical suggestions. There is less research on deadlifting than there is on squatting; however, the research that does exist indicates two major points:
- Lifting (including deadlifting) with a good spinal position minimizes both compressive and shear spinal loading and reduces injury risk compared with that in a flexed spinal position [19-25]
- Deadlifting is more effective than traditional ‘core stability’ exercises for enhancing core activation [26-29]
Mr. Shaginaw discusses how repetitive flexion of the spine increases the risk of injury and this is true. Those who employ deadlifts in the general population, however, realize that there is NO spinal flexion in a well-performed deadlift in most trainees (save competitive powerlifters). Add that to the fact that the deadlift is one of the most effective exercises for developing hip hinging mechanics and maximizing gluteal muscle activation, deadlifts are on my priority list of ‘must-do’ exercises. As a caveat, however, some participants simply do not have the mobility to pull a bar (or other implement) from the floor with good mechanics. Variations of deadlifting including pulling from a raised surface, using a hex or trap bar , starting from the top position and limiting range of motion, and shifting to a sumo-style  pull may be appropriate for these individuals. All of the above speaks again to having clients learn and perform these lifts from a good coach.
Overhead Press & Bench Press to the Chest
I actually don’t have too much of an issue with his rationale for including each of these; however, the context must be explored. As you’ve probably guessed from my comments to 1 and 2 above, technique always trumps load. As part of understanding proper technique, an understanding of the range of motion requirements of each lift is crucial. In both of these lifts, there is very little research supporting or refuting their use, so I have to rely on experience. What experienced lifters will tell you is that there is no better way to improve upper body strength than the inclusion of pressing. I have also heard from many clients and therapists, that improper pressing resulted in significant injury to their shoulders. Again, this comes down to technique and having a good coach assess and teach these lifts.
For both presses, a very good understanding of scapular mechanics, the importance of grip width and arm orientation, and available range of motion are important. As therapists, we know all about proper scapulothoracic mechanics necessary to avoid impingement, and this is no different for pressing lifts. Grip width and arm orientation is best achieved such that the humerus elevates in the scapular plane. This requirement often prevents much of the excessive shoulder stresses of having the humerous too abducted and internally rotated. For range of motion in the overhead press, I agree that if a client does not have full ROM with good mechanics, they should modify their pressing to angled presses within their available range for elevation (ie. incline pressing or landmine pressing). A similar requirement for flat bench pressing dictates that enough shoulder extension (without scapular compensation) is needed. For flat bench pressing, a little extra lumbar extension (powerlifter-style) can greatly help in this area and is safe if performed with good leg drive and good latissimus dorsi stabilization. This is getting into pretty advanced lifting techniques, and as such, again, a good coach is key.
Mr. Shaganaw did make a comment around bench pressing being ‘not functional,’ with which I disagree. For the same reasons improving deep squat strength is functional, so is improving pressing strength; and there is no better way of loading pressing than with flat bench pressing and good technique.
Anything with Heavy Weights
I have quite a bit of difficulty understanding Mr. Shaganaw’s point of view here. Heavy weights, when lifted correctly, are the best way to improve whole body strength. This has a much greater carry over to function than lower intensity functional movements. In contrast, heavy weights, when lifted incorrectly, are a quick method to sustain injury. All of the above discussions point to this: technique trumps load, but heavy loading with good technique leads to better function/performance.
Consider the recent release by the American Physical Therapy Association which stated that exercise programming for older adults is often ‘under-prescribed,’ which limits the benefits of training. They recommend that these clients undertake a strength training program that is designed to maximize the physiological benefits. Strength improvements in a previously-sedentary population can occur with low or high loads for a short period of time; however, continual improvement typically requires heavier loading [32,33]. In addition, older adults have been shown to tolerate higher loading, which in turn leads to greater functional performance gain [34,35].
Implications for Physical Therapists
I’ve said it a few times now, but technique always trumps loading. Loading with great technique; however, is one of the best ways to keep a client (or you!) mobile, strong, and capable. I’ve also referred to the importance of understanding technique for a lift. A good quality strength coach is imperative here; and yes, that can be you, the physical therapist. Don’t rely on your pre-conceived notions of good technique, however. Partner with a strength coach and spend time lifting and getting yourself stronger. This experience will translate to improving your ability to be that coach for your clients.
In summary, here are the "5 Lifts that should be in your treatment plan":
- Squats as deep as possible with good technique and without pain
- Deadlift variations that maximize range of motion while maintaining a neutral spinal posture
- Overhead (or angled) presses in a scapular plane, with good technique, and within available ROM
- Flat (or inclined) presses in a scapular plane, with good technique, and within available ROM
- Heavy loaded, bilateral lifts with good technique and respecting your body’s responses
- Bloomquist et al http://www.ncbi.nlm.nih.gov/pubmed/23604798
- Hartman et al http://www.ncbi.nlm.nih.gov/pubmed/22344055
- McMahan et al http://www.ncbi.nlm.nih.gov/pubmed/23629583
- Gorsuch et al http://www.ncbi.nlm.nih.gov/pubmed/23254544
- Schoenfeld http://www.ncbi.nlm.nih.gov/pubmed/20182386
- Malliaras et al http://www.ncbi.nlm.nih.gov/pubmed/23773532
- Shwartz et al http://www.ncbi.nlm.nih.gov/pubmed/23953954
- Schoenfeld et al http://journals.lww.com/nsca-scj/Abstract/2012/04000/Are_Deep_Squats_a_Safe_and_Viable_Exercise_.6.aspx
- Klein K. The deep squat exercise as utilized in weight training for athletes and its effects on the ligaments of the knee. JAPMR. 1961;15:6-11.
- Meyers http://www.ncbi.nlm.nih.gov/pubmed/5291432
- Panariello et al http://www.ncbi.nlm.nih.gov/pubmed/7856800
- Steiner et al http://www.ncbi.nlm.nih.gov/pubmed/3752342
- Chandler et al http://www.ncbi.nlm.nih.gov/pubmed/2733579
- Kanamori et al http://www.ncbi.nlm.nih.gov/pubmed/10976125
- Li et al http://www.ncbi.nlm.nih.gov/pubmed/15013087
- Li et al http://www.ncbi.nlm.nih.gov/pubmed/10213029
- Markolf et al http://www.ncbi.nlm.nih.gov/pubmed/8764874
- Nisell et al http://www.ncbi.nlm.nih.gov/pubmed/4023661
- Potvin et al http://www.ncbi.nlm.nih.gov/pubmed/1948399
- Potvin et al http://www.ncbi.nlm.nih.gov/pubmed/23915481
- Marshall et al http://www.ncbi.nlm.nih.gov/pubmed/19815318
- Cholewicki et al http://www.ncbi.nlm.nih.gov/pubmed/1758295
- McGill http://www.ncbi.nlm.nih.gov/pubmed/9672547
- McGill http://www.ncbi.nlm.nih.gov/pubmed/9323648
- McGill http://www.ncbi.nlm.nih.gov/pubmed/9109558
- Colado et al http://www.ncbi.nlm.nih.gov/pubmed/22032222
- Hamlyn et al http://www.ncbi.nlm.nih.gov/pubmed/18076231
- Nuzzo et al http://www.ncbi.nlm.nih.gov/pubmed/18296961
- Martuscello et al http://www.ncbi.nlm.nih.gov/pubmed/23542879
- Swinton et al http://www.ncbi.nlm.nih.gov/pubmed/21659894
- Escamilla et al http://www.ncbi.nlm.nih.gov/pubmed/10912892
- Signorile et al http://www.ncbi.nlm.nih.gov/pubmed/15772058
- Raymond et al http://www.ncbi.nlm.nih.gov/pubmed/23473702
- Fatouros et al http://www.ncbi.nlm.nih.gov/pubmed/16183776
- Seynnes et al http://www.ncbi.nlm.nih.gov/pubmed/15123761