Core Training: Bridging Rehab To Performance

Welcome back to Squat University. A few weeks ago I started a blog series on how to address back pain. If you are currently dealing with a back injury, I highly recommend checking out these prior blog articles before proceeding with the following content.

The rehabilitation process for eliminating any kind of pain (regardless of whether it’s back, knee or hip pain) requires a three stage approach. You must first eliminate the cause of the pain in order to decrease symptoms and provide an optimal environment to kick start your body’s natural healing process. While this step seems to be easy, many athletes have a hard time with it. My advice for an athlete to stop squatting or deadlifting for the time being is often met with the line, “I can’t stop completely or I’ll lose the gains I’ve made!”

Have perspective and drop your ego. You need to understand that you will not lose all you have gained by taking a few steps back in the short term. There is no rehabilitation plan or corrective exercise program that will truly fix your pain and restore your body in the long term if you are too stubborn to deviate from a training plan that is currently creating pain. If certain lifts create pain, stop performing them for right now. Have faith that you can and will return to them eventually.

The second stage of rehab is to address your body’s “weak links” that led to your pain in the first place. This will include a well rounded approach of starting back-friendly core stability work like the “McGill Big 3,” mobility/flexibility exercises for restricted joints and retraining poor movement patterns.

Mobilize The Surrounding Joints!

Back problems rarely develop solely due to core instability. While building a strong and stable core should always be a foundation for back rehabilitation, you must always address mobility restrictions at the joints above and below the low back (the ankle, hip and thoracic spine) if you want to truly fix the problem. This is because the low back has a tendency to become unstable in the presence of poor mobility elsewhere in the body.

If you uncovered mobility restrictions through the screening process in the joints above and below the low back, I recommend adding in the following mobility/flexibility exercises into your rehabilitation plan.

Learning The Hip Hinge!

 One of the most common reasons for developing back pain is the inability to properly use the hips.7 From bending over to pick up a pencil on the ground to grabbing a loaded barbell, many who develop back pain have forgotten how to move about their hips and have instead allowed the lumbar spine to become unstable and move excessively. Therefore, learning to move from the hips and keep the spine stable (a movement called a hip hinge) is essential in the rebuilding process.

To learn how to perform a proper hip hinge, start in a standing position with your hands straight in front of you. Grip the ground with your feet (big toe into the ground) and feel for your bodyweight spread evenly across your entire foot. Next, drive your knees out to the side to engage your lateral glutes (make sure to keep your foot foot firmly glued to the ground). Using a small resistance band loop across your knees can be great in the early learning process to teach your body how to create sufficient tension in these lateral hip muscles.

With your arms remaining parallel to the ground, begin a mini squat by pushing your butt backwards and bring your chest forward (no motion should occur at your back). Only squat a few inches down and hold this position for a few seconds. If you did this correctly, you should feel tension building in your glutes and hamstrings!

If you were unable to perform this motion without pain in your back, place both hands on the front of your thighs. As you push your butt backwards and bring your chest forward, slide your hands down your thigh. Placing pressure through your hands into your thigh should create a small amount of stiffness in your torso and upper body. If you did this correctly, you should no longer have any pain in your back.

Using this simple hip hinge (with or without your hands pressing into your thighs) can allow you to bend forward properly without creating symptoms. This means every time you grab foot out of the fridge or pick a sock off the ground, you should be hinging at your hip!

Building The Foundation

Assuming you have properly taken the right steps up to this point, it is now time to progress the rehab plan in order to rebuild your body to handle the high demands of barbell training and competition. Unfortunately, there is no one universal exercise that equally stresses all of the muscles that surround the spine or places the same physical demand on your body. For this reason, we need to create a well rounded training program that requires you to build sufficient core stability through multiple plane of motion and movement patterns. The exercises in this third stage of rehab will fall into four categories.

  1. Push
  2. Pull
  3. Carry
  4. Anti-Rotation

Pulling from each of these categories will help rebuild your body by forcing you to expose and address “weak links” that often go unnoticed in common performance training. For example, a powerlifter will often perform exercises during his or her training that will fall into the “lift,” “pull” and “push” categories (with exercises like the squat, deadlift and bench press). Yet, if he or she never performs any loaded carry exercises (like a suitcase carry), they essentially leave their body open to potential injury as they fail to stimulate core stability in the frontal (forward and backward) plane of motion.

When returning from a back injury, you must take a careful approach during this third step and choose exercises that help facilitate the healing process without placing excessive load on the spine that re-create symptoms. For example, performing anti-rotation exercises before one can successfully squat with light weight can often spell disaster. Exercises that create a twisting force on the body (like the pallof press) can place upwards of four times as much compression on the spine compared to the same weight that attempts to create a flexion/extension force.9

The following is a logical progression of stability exercises that stress the body first through a sagittal plane (flexion/extension torque), then a frontal plane (lateral torque) and finally through a transverse plane (torsional torque). While there is no such thing as an ideal set of exercises for any rehabilitation program, the following exercises can be a spring-board for creating the plan that best suits your body and goals.

Squat

Once you can perform a hip hinge without any pain, it’s time to start rebuilding the squat! Start by performing a bodyweight squat and increase depth as you are able to do so without pain. Depending on the severity of your injury, it may take a few weeks until you are able to regain a full depth bodyweight squat without symptoms. Once you can do so, it is then time to load the movement.

The position of the load (on your shoulders vs back) and the amount of weight being lifted will dictate how much force is placed on your spine. For example, performing a goblet squat with a 30 lb. kettle bell held by your chest will place less force on your spine than a 135 lb front squat. In the same manner, a 135 lb front squat will create less torque on the lumbar spine compared to the same weight in a back squat. The more vertical torso assumed during the front squat in order to stay balanced provides a smaller moment arm (distance from the vertical line of gravity pulling down on the barbell to the joints of the lumbar spine) when compared to the relatively more inclined torso of the back squat.1-2

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I recommend starting with a goblet squat (weight held by chest) before progressing to a front squat and eventually the back squat. Be cautious in how quickly you move through each pattern and how much load you choose to lift. Those who are not patient and return too quickly to lifting heavy weight can easily regress back to injury. I have worked with many strong powerlifters who during their rehab from back pain used the light goblet squat (of only 30-40 lbs) for a few weeks before returning to heavy barbell lifts.

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Once you have returned to lifting ample weight in any of the techniques, you need to focus on how you’re breathing.  When you’re lifting heavy weight it’s not enough to only brace your core, you have to learn how to breathe properly as well!

Contrary to what many medical and fitness professionals are taught, the line “breathe in on the way down and out on the way up” is not helpful for stabilizing the spine when we’re lifting heavy weight. Think about what would happen to the spine of an elite powerlifter if he exhaled completely with 1,000 lbs. on his back!

When we lift heavy weight it is advised to take a large breath in and hold it through the entire repetition. When this held breath is combined simultaneously with the cues to stabilize your core (such as “brace for a punch”) your body will become instantaneously stable and capable of handling tremendous weight. This is how you activate your body’s natural “weightlifting belt.”

IAP Brace

In order to keep this increased pressure in your abdomen and your spinal stability high, your exhale must be forcefully stopped from escaping (this is called the Valsalva maneuver). By grunting or using a “tss” sound as you exhale slowly through a small hole in your lips, you will maintain a sufficient amount of stability in your core and keep your spine safe.5 

This held breath should not be used for more than a few seconds during any lifting as doing so can increase blood pressure (BP) to harmful levels and cause black-outs. If you have a history of cardiovascular issues, speak with your doctor before performing. For healthy athletes however, a small temporary rise in BP is not harmful.

Deadlift

As we reintroduce the deadlift into your training plan, we want to do so in the most “spine friendly” way. Performing the lift off a set of elevated blocks or stack of weights will place less force (shear force) on the low back compared to pulling the barbell from the ground.

If we analyze the deadlift from the side view and “freeze frame” the movement at the exact moment the pull is initiated, we can calculate the amount of torque placed on the low back by determining the length of the moment arm (the distance from the vertical line of gravity pulling down on the barbell to the joint in question, in this case the joints of the lumbar spine).

When performing a deadlift from the ground, the body naturally assumes a more angled torso position compared to when pulling from the blocks. The more forward angled trunk creates a longer moment arm for the joints of the low back and therefore places more load on the spine. Elevating the starting position of the pull (to above the height of the knee or slightly above) will therefore place less demand on the low back.

Performing the deadlift (regardless of whether you use the lift in competition as a powerlifter or in training as an accessory lift like many weightlifters) is all about finding the right balance of pushing your bodyweight into the floor and pulling back on the barbell. I find that many athletes who develop back pain when deadlifting do so because they fail to use their legs sufficiently and end up over relying on their back. As you pull yourself down into your starting position stance, lock your elbows out and try to make your arm pits disappear (squeeze your arm tight to your rib cage). This action will engage your powerful lat muscles and create a tremendous amount of core stiffness and upper body stability.

Deadlift.png

Next, engage the rest of your upper body by pulling upwards against the bar (not moving it from the raised platform yet, but enough to essentially wedge your body against the bar like a “trust fall.” If doing this correctly, you’ll see the bar bend upwards slightly (an action some will call “taking the slack out of the bar.”).

While you’re creating this tension with your upper body you need to simultaneously do the opposite with your lower body. This means creating a tremendous amount of tension in your glutes and hamstrings as you drive your feet hard into the ground. Finding the right balance between pulling on the bar and pushing through the floor will help keep your back safe. As you progress with this lift, you can manipulate the different variables by adding weight or decreasing the box height.

Modifying deadlift technique can also be helpful during the short term rehabilitation process. For example, a sumo style deadlift is often more friendly on your low back compared to the back angle used during a conventional deadlift. The wider foot stance of the sumo deadlift allows the lifter to keep the bar closer to the body and maintain a more upright torso position. Both of these factors shorten the moment arm on the lumbar spine and result in less overall loads.8

 The Olympic Lifts

The Olympic lifts (snatch and clean & jerk) can eventually be added to the rehabilitation program. Due to the complexity and speed requirements of these lifts, I do not recommend reintegrating these lifts into your program until you can easily perform a single repetition at 70% of your prior 1 RM in both the squat and deadlift without any symptoms.

Just as with the deadlift, using blocks initially can allow you to perform either lift with less load on the low back. Start with a block height that positions the barbell at mid or low thigh (above the knee). Research has shown that there is significantly less stress on the low back when the athlete assumes a more vertical trunk position as the barbell passes the knee during either Olympic lift (meaning the start of the full lift from the ground is the most demanding on the spine).10

As you progress with this lift, you can manipulate the different variables by adding weight or decreasing the box height.

Inverted Row

The inverted row (performed with the suspension trainer or gymnastic rings) has been shown in research to elicit a high amount of upper and mid back muscular activation while placing minimal stress on the spine.3 This makes this variation of the row a great exercise in the early stages of rehabilitation from a back injury.

As you perform the row, ensure your back remains in a neutral braced position throughout the entire movement.  As this exercise becomes easier to perform, walk your feet down and angle your body closer to the ground. The end goal should be to assume a parallel position to the ground with your feet elevated on a bench or box.

Sled Push

Successfully pushing a weighted sled requires an athlete to generate tremendous force with the legs and transfer it through a stiffened core into the arms and eventually the sled. If you are unable to create sufficient stability the spine will move out of the ideal neutral position causing energy that would otherwise be transferred into the moving sled to “leak out.”

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Start with your hands high on the sled poles. Before any movement occurs, grip the sled poles as hard as you can and drive your feet into the ground. Along with bracing your core, these actions will help create necessary spinal stiffness to help you drive the sled with incredible power while keeping your back safe.

Suitcase Cary

Most lifts that are performed in the weight room occur in the sagittal plane of motion (the barbell moves in a relatively vertical path with both feet firmly planted on the ground). As athletes spend hours upon hours training these lifts, they can develop weaknesses in creating strength and stability in other planes of motion.

For example, the lateral musculatures of the core (quadratus lumborum and obliques) are not sufficiently challenged during the classic lifts of the deadlift or squat and even the more dynamic movement of the Olympic snatch. If an athlete cannot sufficiently activate these muscles to stabilize the body through different planes of motion they leave their body open to potential injury. Take for instance these two examples.

QL

In order to perform a heavy squat an athlete must first walk the barbell out of the rack a few steps before setting their stance. During the execution of a heavy snatch or clean, an Olympic weightlifter may stumble one foot forward quickly in an effort to recover an off balanced lift. In each case, every step forward or backwards an athlete takes moves the body through the frontal plane of motion.

The suitcase carry challenges the core in the frontal plane and will help address this common imbalance for many athletes. To perform, grab a light weight kettlebell or dumbbell (10-20 lbs to start) with one hand and hold it on your side. Brace your core and squeeze your arm to your side to activate your lats (use the cue for creating upper body tension when setting up your deadlift of “make your arm pits disappear”). Grip the kettle ball handle as hard as you can before you start. As you walk, concentrate on limiting any side to side lean of your torso.

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Performing a suitcase carry with the weight in one hand is significantly harder and a greater challenge to your core than performing the exercise with weight in both hands. In fact, research has shown that carrying double the weight in each hand (using two 30kg/66lb kettlebells) places significantly less compression on your spine than when carrying a single 30kg/66lb kettlebell in one hand.9 This is because your body is being challenged to a greater degree to stabilize the uneven forces moving up your spine by holding the weight in one arm.

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Pallof Press

The lateral banded press or “Pallof Press” challenges your body’s ability to resist a twisting motion. This provides a unique test for strength athletes who rarely encounter twisting forces during normal training with the barbell.

Begin in a standing position with your hands close to your stomach and holding a band/cable. The attachment for the band should be perpendicular to your side. Brace your core and push your hands away from your body (hold this position for 5 seconds without allowing your body to twist).

You can perform this exercise in different positions (half kneeling or tall kneeling), by adding a lift after the initial press and hold, or even perform it in conjunction with a squat. After you perform your first press, squat down a few inches, pause and press again. You can do this again one or two more times until you reach the bottom of your squat.

Recommended sets/reps: 2-3 sets of 10 reps for 5 second hold on each side.

One Armed Row

At first glance most people would classify the one armed row (performed with a resistance band or cable machine) as a shoulder stability exercise to emphasize the strength of the upper back and posterior shoulder musculature. While this is correct, it also provides an excellent challenge to the athlete as an anti-twisting or rotation core stability exercise.3

Stand facing towards a cable machine or attach a band around a rig. Perform a row with one arm while maintaining a neutral spine. Don’t allow your body to twist at all. After a two second hold, extend your arm back to the start position. You can perform this row in a number of different positions (such as in a lunge or kneeling).

Recommended sets/reps: 2-3 sets of 10 reps

The Bridge to Performance

 Once you have eliminated your pain and returned back to your prior level of training, you must continue to maintain your new found core stability. This means performing the McGill Big 3 and other core stability exercises from the prior section on a weekly basis. There is no “right or wrong” when it comes to choosing which of the prior exercises to include, but I recommend you incorporate those that challenge your body in different planes of motion (single arm suitcase carries for the powerlifter for example).

For the strength athlete looking to perform at the highest level, I recommend taking your core training one step further and consider using the following exercise modifications in your training.

  • Paused Deadlifts
  • Zombie Front Squats
  • Squats with Chains

Paused Deadlifts

The pause deadlift is a great variation to help reinforce proper pulling technique. To perform start with the exact same approach as you normally would. Take a huge breath and brace your core before then squeezing the bar from the ground. You can perform 2-5 second pauses in a variety of positions such as mid-shin, below the knee and above the knee.

During the pause, feel your legs pushing hard into the floor. If you are maintaining sufficient core stability by holding your breath and bracing your core, you should not feel any reoccurring symptoms in your low back. Perform up to 3 reps per set.

Zombie Front Squats

When performing a front squat or clean, we want to maintain as much of an upright trunk as possible. Athletes will commonly hit a decent looking bottom position with each but will fail to maintain an upright torso on the ascent, allowing their back to cave over. The no-hands “Zombie” front squat solves this problem.

Start with a barbell held on your chest as if performing a front squat. Take your hands and hold them straight out in front of you so that the barbell is resting solely on the tops of your shoulders and chest. Set your feet in a stable position by grabbing the ground with your toes. Take a big breath, brace your core and begin your squat.

In order to maintain the bar on your chest and keep it from rolling off and onto the ground, you must keep an upright torso! Start with sets of 1-3 reps with light weight and only progress in weight as you can maintain perfect technique.

Squatting with Chains

The use of chains when lifting has been a popular method in the powerlifting community for many decades since first introduced by Louie Simmons of the well-known Westside Barbell.4 The theory behind their use is to accommodate for how the body naturally responds to moving weights (called the force velocity curve).

For example, everyone can picture that one guy who does quarter squats with a lot of weight on the bar but has zero chance completing the same weight full depth. This is because the force your body is able to generate is much greater at the top portion of the lift compared to the bottom.

Let’s say for example an athlete’s 1-rep max squat is 300 lbs (137kg). They could load a barbell to 220 lbs (100 kg) and hang 2 chains per side at 20 lbs each. The total weight of the top of the lift would then be the lifters max). As he or she drops into the bottom of the squat, the chains hit the ground which decreases the overall weight pulling down. During the ascent the weight is then reapplied to the barbell.

Using chains unloads the overall weight being lifted in the weakest portion of the lift (the bottom) and adds to the strongest portion of the lift (near the top) effectively accommodating for the natural force velocity curve of the body during the lift. Using this method can help an athlete improve their bar speed and power through the sticking points of the ascent.

Another less recognized benefit of using chains during lifts like the squat (and the reason I like using them during for athletes with a history of back pain) is to work on core stability. The light swing of the chains as they hang from the barbell places uneven and irregular stimulus on the lifter (a similar concept to the use of rhythmic stabilization drills to enhance neuromuscular control). If they fail to adjust and stabilize their body during the lift they will fall off balance and performance/technique will suffer.

Final Thoughts

The process of returning from a back injury can be a daunting task. Some people will be able to return quickly from a back injury while others will not. However, the more diligent and patient you can be with each step of the process the greater chance you give yourself to return to lifting pain free.

Until next week,

Author Photo
Dr. Aaron Horschig, PT, DPT, CSCS, USAW

With

Kevin Photo
Dr. Kevin Sonthana, PT, DPT, CSCS

References

  1. Diggin D, O’Regan C, Whelan N, Daly S et al. A biomechanical analysis of front versus back squat: injury implications. Protuguese Journal of Sport Sciences. 11(Suppl. 2), 2011; 643-646
  2. Hartmann H, Wirth K, Klusemann M. Analysis of the load on the knee joint and vertebral column with changes in squatting depth and weight load. Sports Med. 2013; 43:993-1008.
  3. Fenwick CM, Brown SH, McGill SM. Comparison of different rowing exercises: trunk muscular activation and lumbar spine motion, load, and stiffness. J Strength Cond Res. 2009;23(2):350-8
  4. Siff, MC and Verkoshansky, YV. Supertraining. Denver, Colorado: Supertraining International, 1999. pp. 1–3, 88–90.
  5. Hackett DA & Chow C-M. The valsalva maneuver: its effect on intra-abdominal pressure and safety issues during resistance exercise. JSCR. 27(8):2338-2345.
  6. McGill SM, Marshall L, Anderson J. Low back loads while walking and carrying: comparing the load carried in one hand or in both hands. Ergonomics. 2013;56(2):293-302
  7. Nelson-Wong E, Alex B, Csepe D, Lancaster D, Callaghan JP. Altered muscle recruitment during extension from trunk flexion in low back pain developers. Clin Biomech. 2012;27(10):994-8
  8. Cholewicki J, McGill SM, Norman RW. Lumbar spine loads during the lifting of extremely heavy weights. Medicine and Science In Sports and Exercise. 1991;23(10):1179—1186
  9. McGill SM. Ultimate Back Fitness and Performance5th ed. Gravenhurst, Ontario: Backfitpro Inc., 2017.
  10. Enoka, RM. The pull in Olympic weightlifting. Med Sci Sports. 1979;11:131-137.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Published by

Dr. Aaron Horschig

Doctor of Physical Therapy, CSCS, USAW coach and athlete.

2 thoughts on “Core Training: Bridging Rehab To Performance

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