The selection of client-appropriate exercises can be a challenging task for a fitness professional. For the novice fitness professional, exercise selection often is based upon exercises from textbooks or exercises that the individual has seen other trainers/trainees perform. In both cases, there may be alternative exercises for the fitness professional to use that better serve their client. When working with a client base that may be prone to chronic injury, as a growing number of middle-aged adults seem to be, alternative, evidence-based exercises may be a way to prevent injury. In 2013 alone, there were more than 10 million individual doctor’s office visits for both lower back pain and shoulder symptoms (28).
Because overuse injuries can be difficult to diagnose, treat, and recover from (8), the task of safe and proper exercise selection becomes more important and may even assist with prevention of overuse injuries. Evidence exists indicating several exercises that were once fitness standards are now believed to either initiate a novel injury or exacerbate an existing injury (1,4,8–11,13,14,17–22,24–27). We have identified two anatomical locations — the shoulder joint complex and the lumbar spine — where the combination of previous injury and inappropriate exercise selection may escalate potential soft tissue damage. In an effort to avoid such a combination, it may be beneficial to select more modern, evidence-based alternative exercises, as opposed to some of the traditional fitness standards mentioned hereinafter.
Because overuse injuries can be difficult to diagnose, treat, and recover from (8), the task of safe and proper exercise selection becomes more important and may even assist with prevention of overuse injuries.
One area where the incorporation of alternative, evidence-based exercises may be of particular importance is the shoulder joint complex, due to this joint's relative importance for sporting activities and activities of daily living. Historically, exercises used to train this area often produce torque in extreme ranges of motion (ROMs), leading to shoulder capsule stress or nervous and ligament impingements (3,8,11,13,26). Some examples include the behind the neck lat pulldown, behind the neck shoulder press, and triceps bench dips. Specifically, an increased risk of anterior capsule instability, suprascapular neuropathy, and rotator cuff impingement has been shown with both the behind the neck lat pulldown and shoulder press (8,11,13,26). In addition, an increased risk of impingement syndrome and posterior capsule stress has been shown with triceps bench dips (8,11).
As shown in the Table, there are several evidence-based alternative exercises that can illicit similar, if not better results, and do so with a decrease in risk of injury. For both the behind the neck lat pulldown and shoulder press, moving arms to 30 degrees forward in the scapular plane is suggested as a safer alternative. In addition, this placement allows for greater weight to be lifted, better mechanical advantage, and increased sport specificity (8,11,13,25,26). With respect to the triceps bench dip activity, there are two alternatives suggested within the research. First is a traditional push-up or modified push-up. By adjusting to this exercise, shoulder stabilization muscles, such as the serratus anterior, are better activated and strengthened (3,15). Second, it is suggested that if a client has any previous posterior shoulder capsule instability, body weight exercises are not recommended and a triceps pushdown exercise on a cable machine is the recommended alternative (3,8,11,15).
A second anatomical area for which exercise selection may be important for injury prevention is the musculature surrounding the lumbar spine, popularly known as the “abs.” Exercises used to train this area often focus on dynamic efforts of lumbar extension, flexion, lateral flexion, and rotation — and these movements may or may not be loaded. The names of these exercises are familiar — the Russian twist (loaded lumbar rotation), the dumbbell side bend (loaded lateral flexion), straight leg sit-ups, alternating crunches (both lumbar flexion), and back hyperextension or “Superman” (lumbar extension). Evidence indicates that these exercises may exert one or multiple stressors on anatomical components of the lumbar spine. Specifically, interverbral disks are at increased risk of degradation during loaded lumbar rotation (21), increased risk of herniation during loaded lateral flexion (1,4), and increased compression during the straight leg sit-up exercise (19). In addition, ligaments within the spine may receive undo stress during repeated lumbar extension exercise (23).
It is generally understood that the primary purpose of muscle is to produce joint movement, with a secondary purpose of joint stabilization. However, with respect to the core musculature (erector spinae, rectus abdominis, internal and external obliques), some exercise authorities believe that these functions should be reversed. McGill (24) asserts that the purpose of these muscles is to prevent motion rather than to produce motion, and Kibler et al. (16) contend that a well-conditioned core functions as a rigid cylinder that promotes lumbar spine stiffness. Consequently, these fitness professionals feel that core training programs should focus on static exercises that emphasize lumbar spine stability rather than on dynamic exercises that enable lumbar spine movements such as trunk flexion, trunk extension, trunk lateral flexion, and trunk rotation (Table).
It is generally understood that the primary purpose of muscle is to produce joint movement, with a secondary purpose of joint stabilization. However, with respect to the core musculature (erector spinae, rectus abdominis, internal and external obliques), some exercise authorities believe that these functions should be reversed.
Although the authors recommend static exercises to enhance core stabilization, we realize that many fitness trainers, trainees, and enthusiasts may choose to perform more traditional dynamic exercises.
Therefore, we have included the best evidence-based versions of these two particular exercises to minimize injury risk for individuals who desire to use these movements. In addition, because low back pain is one focus of this article, and low back pain often is partially addressed by focusing on the improvement of hamstring flexibility, we have included a commonly used hamstring stretch (the hurdler’s stretch), its potential risk, and an evidence-based alternative to this commonly used stretch (Table).
The process of appropriate program design can be complicated, but this practice can be simplified somewhat by considering the removal of specific exercises that may be inappropriate for many populations. Evidence was presented in this article to support the replacement of several exercises due to increased injury risk (1,4,8–11,13,14,17–22,24–27). Evidence-based alternatives to each movement were recommended and described. These alternative exercises promote a similar, or in some cases, more beneficial training effect and also have a low injury risk. (2,3,6–8,11,13,15,17,19,20,23–27). Practitioners are well served to choose exercises with a low risk-to-reward ratio, regardless of the health/injury status of the client or patient. Thus, there is nothing to lose by adding the alternative exercises suggested in this article to an exercise selection library and using them with both healthy and deconditioned populations.
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Keywords:© 2017 American College of Sports Medicine.
Overuse Injury; Low Back; Shoulder Impingement; Fitness; Musculoskeletal