“Which is the best exercise for my low back pain? Or for my patellar tendinopathy? Or for my shoulder impingement? Or to avoid the recurrence of my hamstrings tears?”. For sure you have been hearing these questions for ages. Is there a solid answer to those questions?

My answer is NO! There are not exercises for pain – pain-free movement changes pain output, that’s different -, or for a specific injury. You should not choose an exercise based only on the type of injury you are dealing with or the injury you want to reduce risk.

Thinking in exercises for injury X, is like thinking that everytime someone has fever, Ibuprofen is the solution. However, fever is just a mechanism to protect the body. Fever can be caused by a huge amount of sources, from an infection within the big toe’s nail to a cancer. Sometimes, Ibuprofen is enough and nothing wrong happens, however it can be the worst thing you can do, since it can disguise a protective mechanism from your body, and the risk-reward ratio is extremely high.

The same happens with the neuromusculoskeletal system. One size fits all approach is not the best option. I agree that sometimes it works, and it could be better than doing anything, but for sure it will not benefit every single patient/client/athlete. Very often we see athletes doing “injury prevention programs”, where a group of, let’s say, 20 people – all different from each other, with different injury and training history and with different needs – are doing the same exercises, in order to prevent injury and enhance performance. While this is better than doing nothing in the short-term, especially if you are an untrained individual, for sure is not the best option in the long-term, and it can inclusively expose them to greater injury risk.

So, “if exercise recipes are not the best option, what should I do?” – you are probably thinking.

1. Methods vs. Systems

Professionals are often influenced by a methods-based mindset. Instead, we should guide our intervention by a principles-based approach. In other words, we should not guide our intervention by the tools (exercises or techniques) we have at our disposal. However, we should adapt and select our tools after we know what we want to accomplish, or by the principles that guide us.

As Ralph Waldo Emerson stated, “as to the methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.”.

Putting this, and giving the analogy of cooking something, you can have all the ingredients to cook a cake – eggs, flour, sugar, butter… – but if you don’t know how to put everything together with the right amounts and timing, and mainly, if you don’t know what type of cake you want, you will end in not cooking a cake, but something else.

It’s better to have a tool box where we can put all the tools we have, than having a hammer, a pliers and a screwdriver separately.

2. Regional interdependence 

Regional interdependence can be defined as “the concept that a patient’s primary musculoskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s)”. “In this definition, impairments are not limited to the musculoskeletal system and include those that may originate from other systems, which may contribute to or influence the patient’s primary musculoskeletal complaint(s).

The concept that the function and health of one region of the body could potentially affect the function of another region is not novel. Inman and Saunders (1944) stated that both clinical and experimental evidence indicated that pain could be experienced over a considerable distance from the site of the local lesion and Slocum (1959) stated that it was not uncommon for a baseball pitcher with an injured toe or foot to lose the effectiveness of the shoulder joint.

From these published beginnings, backed by clinical observation and established clinical practice patterns, additional works under experimental conditions began to appear that supported the clinical interdependent relationship between regions of the body. Cleland et al. (2005), Fernandez-de-las-Penas et al. (2009) and Gonzalez-Iglesias et al. (2009) have all demonstrated that interventions focused on the thoracic spine could affect impairments in the cervical region. Similarly, Currier et al. (2007) and Souza & Powers (2009) have both provided evidence that treatment of the hip could alleviate impairments located at the knee. Since it was editorialized by Wainner (2007), multiple studies have been published that directly reference the concept of regional interdependence.” – extracted from Sueki, Cleland & Wainner (2013).

Putting all together, we can easily conclude that exercises for specific injuries prevention and/or rehabilitation is a wrong approach. Simply because the same injury in two different subjects, can be related to completely different things.

3. Movement implications

Everybody has different movement strategies. It’s impossible to create a general rule or law regardind movement, due to anthropometric differences, anatomical variations, etc. This is a huge reason why one size fits all approach is not the best option, simply because everybody is different.

Despite anatomical variations, movement should be screened, evaluated and assessed regarding its quality. First of all, we should have full ROM in our joints and tissues. A few days ago, I described the importance of full ROM to proprioceptive input – CLICK HERE. If mobility is reduced, the awareness of the proprioceptors will be negatively affected. If this is the case, motor control will automatically be affected, so compensation have to occur.

The human body is a very advanced machine, so it always tries to maintain function, even if it is not at full gear. It’s like a computer, in case of trouble, you can run it in safe-mode. However, it can only maintain this safe-mode temporarily, in the short-term. This is quite good actually. The problem is when compensation becomes the norm, and it will become a problem in the long-term, especially if you are adding load or volume to that compensation.

This is why generic “injury prevention programs”, performance enhancement programs or exercises to rehabilitate specific injuries are not the best option. They can result in a positive outcome, but as I said before, the risk-reward ratio can be high, especially when you are working with athletes with an extremely high commercial value. For some, an exercise can be quite good, if he has the minimum requirements to benefit from it. However, for others, it can even become harmful, since it can lead compensation to occur, which will become a problem in the long-term.

Practical example: squats can be great to reduce injury risk, enhance performance and even rehabilitate injuries. However, we should not assume that squats are great to everybody. If someone has ankle mobility deficit, hip mobility deficit, poor motor control and motor program, he should not even be squatting, especially with load. It can even look “clean” regarding technique, but it will only feed compensation, which will become a problem in the future.

This is why generic programs can increase injury risk, instead of reducing it.

4. Putting all together

The best way to design performance enhancement, injury prevention and rehabilitation programs is to screen, evaluate and assess people individually. Whether you work in a group/team setting or a single person, screening, evaluation and assessment are mandatory. If you do not do this, how will you be able to program something? As stated before, one size fits all approach can be better than nothing for some, but can be even harmful for others – it really depends, but it is not the best option, for sure.

After screening, evalutation and assessment, program should begin by the end, and not by the beginning. What I mean is that we should have several generic programs created. Then, each individual program will be adapted to the specific needs and limitations of that particular person.

Imagine you work with a sports team, and you want to include squats as an exercise in your program design. You have realized that 3 athletes from your team have ankle mobility limitations, after you assessed them. In this case, those 3 athletes will not be doing squats until ankle mobility is restored, instead they should be doing ankle mobility drills, while all the other athletes will be doing squats. The same goes with deadlifts. If you have an athlete who has a significant assymetry in Active Straight Leg Raise between both limbs, he shouldn’t be doing bilateral deadlifts, and he should be doing unilateral deadlifts or no deadlifts at all.

So you will be eliminating more exercises from the program than adding. However, you should introduce specific exercises to each player, in order to increase their mobility and motor control. This can be accomplished within a Prehab block – specific to the individual – before movement preparation (traditionally warm-up – more on this in a near future) – specific to the following session – , and also as active rest drills between strength/power program.

This way you can still work in a group setting or regime, without feeding compensation and leading to an increase in injury risk in the long-term.

Luís Mesquita

REFERENCES

1. D. Sueki, J. Cleland and R. Wainner (2013). “A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications”. Journal of Manual and Manipulative Therapy 21(2)