Wednesday, November 06, 2013

My knees feel great, but my back hurts.

This is my second blog post about squats and knees.  The first talked about why a group exercise instructor might give different instructions than a personal trainer regarding the same exercise.  A group exercise instructor in charge of many people is going to give cues that keep the majority of them safe, even if it means omitting exercises that could be done with no problem by many people (and in fact are done every day).  A personal trainer, on the other hand, is paid to assess the individual and make recommendations on exercises and movements based on that person's present fitness level, injury history, and goals.

This post is not intended to be an exhaustive study of proper squat technique.  I'm just going to mention one unintended consequence that I've seen in group exercise classes when the following cue is given all by itself.

Most of us have heard that cue.  I've given it.  And it's not technically wrong.  But I don't like it any more.

Here's what I see a lot of.  This is me.  I didn't inflict it on anyone else!  I'm going to follow the knees-behind-toes cue, and see how far that cue gets me absent other information.

The knees are well behind the toes just like the cue says.   Problem is, in over-focusing on keeping the knee back, I've shut down mobility (in this case, flexion) in my ankle.  When my ankle stays relatively locked and my knee bends, the only way I can keep squatting without falling over is to over-hinge in my hip joint, putting un-needed stress on my low back.  My video shows me keeping my head up and shoulderblades down, but sometimes this squat is accompanied with a head drop and a lurch forward in the upper back.  Ouch!

What really drives me nuts is when people get down into this squat and pulse there by moving only their knee joints; the glutes bounce up and down but the back stays low and the ankles stay locked.

This is a problem for several reasons.

1)  The most obvious is the stress on the low back.
2)  A quieter problem, but still a problem, is the lack of mobility in the ankle.  We need ankle mobility and calf flexibility to stand, to walk, for basic function.  A well-done squat promotes mobility in the ankle.
3)  It's not functional!  OK, maybe if you're are a jockey.  But if you are not a jockey, the risks of hurting the back and reduced ankle mobility outweigh, in my opinion, the benefits of the glute bounce.

Let's view a better squat (from a knee perspective) for a moment.  Thank you, B. and T. for letting me use you as examples.

Here, the knee is still behind the toes for the duration of the movement, but notice that it gets closer to, and further away from, the toe throughout the squat.  The whole motion is like the coiling and rebounding of a spring - three joints are moving - the ankle, the knee, and the hip.  Since the ankle is also moving, the back isn't as hinged over, creating less strain on the low back.  The concept is called triple flexion.  All three joints share the load.

How could / should this be cued?

Here are a few things that I do to get safe and effective squats in group exercise situations where I don't have time to lecture for long or spend one-on-one time (unless someone is acting really dangerously, then I will correct them).

1)  I pre-educate members about "triple flexion" before class, and then I can say "triple flexion" as a quick cue that reminds them about the shared load on all joints.
2)  Or I'll say - "Bend three joints - hip / knee / ankle and keep your chest up."  Sometimes it's easier to cue a more obvious part of the body.  When I say chest up, I really mean flex the ankles.  If they can't keep their chest up, chances are that they're not flexing the ankles.  (note: this cue works most of the time but sometimes people will flex at the ankle and the knee but not at the hip, then we get knees way out in front of the toes, so it's important to emphasize all three)
3)  Or I'll say - "Drop the hips back and keep the chest up."
4)  This one depends on how good of a sense of humor your class has.  "You have to go potty, but the toilet seat is dirty so you have to hover over the seat.  BUT, you don't want to pee on the back of your shoes.  Don't look down!!!"  This actually gets great compliance but don't say it if it's going to get you fired.

Takeaway lesson

What's the best cue ever?  There's not just one.  But good cues are:
Meaningful to your audience.
Concise, yet complete.
Gets the highest rate of compliance, without creating safety issues, dysfunctional movement, or offense.

Sunday, November 03, 2013

...But my trainer told me.....

I want to thank member Jeff from one of my personal training classes for asking this question most recently. It's a question I address often in small-group training, so I thought it a worthy topic for member and trainer co-education.

I have two points to discuss regarding a common fitness cue.  This post has gotten longer than I thought so I'm only going to address this first point in today's post, and will follow up shortly with point two.

(1)  Why group exercise instructors and personal trainers cue differently, and how neither is wrong.
(2)  Why the "knees behind toes" is an ineffective, and possibly harmful, cue.

(1) Group Exercise Cues v. Personal Training Cues.

If I had to write a list of the cues that I've heard (and given) in group exercise classes throughout my fitness career, I'd have to say one of the cues that rises near the top of the list is this.

This cue is so prevalent in the fitness industry that our members can quote it, so I'm going to use it as my example, throughout this post.  

When I've got my group exercise hat on...

It's 9:00am and I'm introducing myself to my exercise class.  It's a big class, and I know many participants by name, yet I don't have their health histories to know what their injuries are.  Also, during a group fitness, it's not in my scope of practice to customize a one-hour dance class for every injury.  Lastly, there are always new people attending class and many of those newbies sneak in quietly after I've already started my warm-up; their bodies are a complete mystery to me.

Given 20-50 people in my class, no time to assess, and the job of giving a safe and effective class to a mixed-fitness group of exercisers, the fitness industry has given me a set of guidelines for how to keep the majority of people safe in class.  They're called contraindications, and instructors are supposed to avoid those movements in group classes.  Knees over the front of the toes while squatting is contraindicated in a group exercise class.  

In order to keep as many people safe as possible, fitness certifications are conservative in their recommendations.  We instructors have to keep a large group of you safe and this is the easiest way to do it, avoid the things with the highest statistical risk of injury, even though the probability of injury is relatively small.  Common injuries in the general population are shoulders, knees, and low back.  These members are allowed in our classes, so we "protect" them with contraindications.

Group-ex is a hard job.  Sometimes it's like herding cats.  We want everyone to be safe and to give you an effective workout, so sometimes we will avoid things that one individual or several individuals could do quite well.

Personal Training hat on now...

Most people call it personal training.  I see it as personalized training.  It's quite different than group exercise. You are paying for information specific to you.  I train one person at a time (or in a small group) to achieve their fitness goals.  It's more personal, I get to know your body, your physical tolerance for exercise, your preferences.  I assess you, formally and in detail during our first one-on-one session.  I assess you during each session, providing individualized, real-time, feedback so you can get better right away.

It's my job to ask you about your injuries, and to avoid doing you harm.  

It's my job to send you to a doctor if you have an injury.  It's not in my scope of practice to diagnose you, but it's within my scope to support a doctor's or physical therapist's exercise / rehab prescription.  When you tell me about what you've injured, I'm gonna go look it up and be sure that nothing I ask you to do is going to make it worse (Jeff, if you're reading this, that's why I asked you which one of your 5 muscles you hurt, so I could go home and figure out whether I had to be careful with you in hip adduction, rotation, flexion, or all three).

AND, it's my job to ask you about your goals.

"No exercise is contraindicated for everyone; every exercise is contraindicated for someone."

When I put together a mental picture of your injuries, your current fitness level and your goals, I can make recommendations that will be suitable for your lifestyle.  For example, we're getting near ski season and several of my clients are skiiers.  If your knees are healthy, and I know that you're a skiier, here's what I'm going to consider.  You need to have endurance in a position with shins flexed against your boots; the knee is right up to the toe and possibly beyond.  I'm going to need to make sure you can flex at your ankle, which means I have to stretch your calves, and you're going to need quadriceps and glute strength, plus lateral knee stability.  How am I going to prepare you for a high-intensity activity where the knees track near and over the toes if our training exercises never align your knees near your toes?!?  I wouldn't focus solely on training you with your knees in front of your toes, but I certainly wouldn't forbid it.  Plus, you already do it every day.

Got a second?  Try one or more of these things.

1)  Sit on the toilet
2)  Go up stairs
3)  Get up from a sofa or other soft chair.

I rest my case.

In conclusion, your personal trainer and your group-ex instructor might say things that are different.  When there's a difference in what you're hearing from two fitness professionals, ASK QUESTIONS!  If you ask your instructor or trainer a question and they look at you like a deer in headlights, ask them to please find out for you.  Fitness is a large and ever-evolving field.  Even the best trainer won't know everything, but a good trainer will look it up for you.  Another thing to consider is whether your instructor and/or trainer are certified in their activity, and whether their certifications are current.  Current education matters (I also hold a license CPA, but it's dormant, so you would not want me to do your taxes)!

Please keep in mind that this is one instructor/trainer's opinion, without reference citations.