How many times have you been asked the question “Is [fill in the blank exercise] bad for my [fill in the blank joint or body part]?”
Your answer should sound something like “It depends.”
The goal of this article is to create a dialogue about “popular” exercises for the general population that have potentially too high of a risk for the low reward they provide. As we talk about each exercise, keep in mind the profile and lifestyle and work style of the “typical” client.
Most of us work with the desk jockey: someone who spends eight to 10 hours a day slumped over at a desk, with internally rotated shoulders, kyphotic (i.e. rounded) thoracic spines, and egregious forward head posture (also known as tech neck).
While it is possible to argue that every exercise has its place, I contend that this may only be true as long as the exercise prescription is preceded by a proper assessment, movement evaluation, injury history, and an honest evaluation of the potential risks and benefits for each individual client.
My perspective in this article comes first as a doctor of physical therapy practicing sports performance orthopedics. Second, I am a lifelong athlete, heavy lifter (who got my start as a youngin’ in the meat-head bro-science world of bodybuilding in Long Island), and a certified personal trainer and strength coach of 18 years’ experience. Third, I have personally been on all sides of the athlete-fitness-injury spectrum with countless injuries such as tears of the rotator cuff, low back pain, and three (yes, three) ACL reconstructions.
This all matters because I’m not just sitting behind my computer giving my opinion. I’m in the clinic, deep in the research, on the field, and in the weight room, walking the walk.
Risk vs. Reward Checklist
Here are a few questions to keep in mind when generally evaluating the risk and reward factor:
Is the exercise critical to helping them achieve their goal?
If yes, is the exercise likely to cause the client acute pain?
If yes, regress or change the movement pattern.
If no, does the client have existing pathologies that make the area vulnerable to reinjury with this exercise?
If yes, are there suitable alternatives that are safer and provide less risk?
If yes, do they have a mastery of the activation and movement pattern?
If no, regress or change the movement pattern.
If yes, can they perform the exercise without compensation up or down the kinetic chain?
If no, regress or change the movement pattern.
This bench dip is a popular exercise around the gym. It has a high level of recruitment of the triceps, which makes it easy for the client to “feel the metabolic pump” in the tissue.
The issue here is that the dip movement pattern itself can pre-dispose our shoulders to dysfunctional mechanics.
Let’s begin with the three scapulo-humeral positions that are required and must be maintained for safe and protected loading during the dip: retraction and depression of the scapula, and external rotation of the humerus. As the body lowers down during the eccentric phase of the dip, the humerus often sneaks away from its safe, externally rotated position, into internal rotation. (Thus why the cue “keep your elbows pointing straight back” is so important!)
This compensation can set the stage for the impingement mechanism in the shoulder, and can often trigger the following cascade of compensations that can reduce stability and can increase risk for injury across the entire region:
Forward head posture (flexed cervical spine)
Shrugged shoulder positioning (loss of scapular depression)
Kyphotic thoracic spine (loss of scapular retraction)
Rounded lumbar spine
No hinge at the hips
How many of those compensations reinforce the average clients’ abnormal sitting posture at work? Most clients will not benefit from the programming of an exercise that reinforces those exact negative postures.
Additional problems arise during the eccentric phase of the dip because the shoulder is often pushed past the clients’ normal extension range of motion. This extreme position forces the head of the humerus to excessively translate forward, placing increased pressure on the anterior joint capsule.
For most, the potential risks the dip places on the shoulders may outweigh the benefits of that deep burn they feel in the tricep.
With only two or so hours of facetime with our clients each week — if we’re lucky! — I believe that, as often as possible, we should be programming movement patterns that offer the greatest functional carry-over to not only optimizing what they do in the gym, but in their lives as well.
Flexion of the lumbar spine in itself is essential to maintaining healthy discs and adequate muscular flexibility and joint mobility. All lumbar flexion, however, is not created equal.
Repetitive lumbar spine flexion, especially with an added compressive load (ball, bar, dumbbell, etc.) can put the lower back complex at extreme risk.
The Glute-Ham Developer machine (GHD) sit-up, popularized in Crossfit competitions, is an example of such exercise.
The danger here is twofold: the eccentric phase of the sit-up requires the entire spine to travel into, and often past, its anatomical limit of extension. This action is typically performed with a weighted ball overhead, thus placing dangerous pressure on the facet joints.
Compounding the issue, the GHD sit-up is often done at high repetitions through a state of fatigue. As the set wears on, and as the client repeats different training bouts over time, a perfect storm of forces are generated that can exceed the tissues’ ability to adapt to the stress. As a result, the athlete may experience issues like lower back pain, spasm, or facet compression, all of which can sideline even the strongest athletes.
Some Crossfit coaches claim that the movement can be made “safer” by not taking the ball all the way back to the ground behind them, thus only extending to where a neutral spine can be maintained.
But I would argue two things:
First, performing this movement safely may only be possible for someone who already has a strong core and deep awareness of “safe” pelvic and lumbar positioning during rapid repetitive motion at the hips. Sadly, once the competition element is entered into the equation, form and precision are often sacrificed for speed and reps.
Since the competition has the potential to increase the risk level, AND the average person is NOT competing to begin with, it might make more sense for most people to opt for a more efficient core training exercise that bares a less risky movement pattern.
Which leads me to my second rebuttal: we must think about functional carry-over when programming exercises. When it comes to the spine, the goal of most strength training programs is the same, whether they’re targeting athletes or the general population: in order to support the compressive loads of barbells and dumbbells, we reinforce a non-moving, stable spine, and avoid flexion and extension.
This “fixed” spine allows for the safe transfer of forces to the other joints (like hips and shoulders) so they can do what they do best: create movement and generate power — think squats, lunges, pressing, pulling, etc. As coaches, we must think about the ultimate functional carry-over of the exercise we choose and how it fits into our clients’ overall training goals.
Therefore, for the general population, core training should focus on what these muscles do for us in the gym and in real life, and prevent motion at the spine instead of creating it.
American Kettlebell Swing
The great kettlebell swing debate!
The Russian Kettlebell Swing (RKBS) is a rapid hip hinge which ballistically takes the bell between the legs, followed by explosive hip extension that drives the bell to the height of the shoulders. This is followed by a rapid eccentric return of the bell to the start position. The goal is to build explosive strength and power at the hips and to optimize mechanics to keep the bell in a safe path of travel.
The American Kettlebell Swing (AKBS) follows a similar pattern as the RKBS, but the kettlebell is taken all the way above the head, instead of stopping at the shoulders. The goal is to get “more work done” by not stopping the kettlebell “halfway.”
If you are a RKBS purist, you may think the AKBS is blasphemy. But let’s put traditions aside and look at rationale, biomechanics, and the body’s ability to safely control this weight through space, at different phases of the AKBS.
Common AKBS Compensation Dangers in the Overhead Position
The following compensatory patterns and sloppy postures often occur at the end position of the AKBS, while the kettlebell is overhead. They run the risk of compromising soft tissue and joint safety, increasing injury potential, and detracting from intended positive training benefits.
Increased lumbar lordosis and anterior pelvic tilt — in an attempt to gain core stability, this poor alignment takes the work away from the muscles of the core, paraspinals, and hips, and places it on the boney and non-contractile structures. It’s what we call “hanging on your ligaments.”
Extreme forward head position — which places increased strain across the cervical spine while reinforcing the exact poor posture that most engage in all day at work.
In my experience, this occurs because the RKBS — and thus the strong hip extension movement from the glutes — was not mastered first.
AKBS Shoulder Impingement Potential
Since the hands are held close together in the AKBS, when the weight is in the overhead position, compression can occur between the acromio-clavicular and gleno-humeral joints. Due to this hand placement, the shoulder joint is forced to internally rotate at this awkward position, which combines end-range flexion and abduction. This further compromises the subacromial space, and sets up a perfect storm for a nasty impingement.
To reduce this risk, overhead kettlebell motions were traditionally designed to be done with one hand, not two. The kettlebell snatch, for example, gives the shoulder a greater degree of freedom by allowing it to slightly externally rotate, thus staying away from full abduction.
Glute, Core and Shoulder Training with the AKBS
If you are looking to train glute strength and power via the explosive hip extension of the swing, the AKBS does not provide any additional benefit over the RKBS. After full hip extension is reached, the entire second half of the AKBS movement does not come from the hips, but is driven either through the arms or through momentum, therefore offering nothing more than the RKBS does.
In terms of training core strength, both methods do a great job… when done correctly. However, the potential danger of the AKBS is that many people will find it difficult to adequately stabilize the spine as the bell travels through the extreme path of motion from overhead at such an advanced speed. To account for this, the weight often has to be reduced, thus decreasing potential gains in strength and power.
Finally, if you are looking to train the shoulders (a common rationale for the AKBS), for all of reasons laid out above, there are hundreds of more biomechanically optimal movement patterns that will do a safer and perhaps more efficient job.
Can the AKBS Be Programmed Safely?
If programming the AKBS, first ask yourself:
Do I understand the exact outcome I am looking to achieve by having my client take the kettlebell overhead, and will this exercise achieve that?
Does my client have the requisite range of motion in the shoulders, scapulo-thoracic region, and cervical spine to achieve the full overhead position without compensations or faulty mechanics?
Does my client have the dynamic shoulder and core stability to keep the bell safely in place once it’s overhead, even for a second, without compensating?
Can my client safely control the kettlebell as it drops from the overhead position? (i.e. Do they own the dynamic core stability in both the eccentric, concentric and ballistic phase that lives in between the two?)
If the answer to any of these questions is NO, the AKBS is not your jam, baby! The risk is too great for the reward it may provide.
What keeps me up at night is that most injuries that our clients experience as a result of training are not acute in nature. They don’t occur right in front of your eyes, or as a direct result of a single rep. Most often, breakdown happens over time, as the cumulative result of repetitive micro-traumas from faulty mechanics that go unchecked, and that the body withstands until it can’t.
Therefore, every decision we make affects the short and long term health of our clients.
As a coach, you have the safety of your clients’ lives in your hands. Program, coach, and cue accordingly.
The action of the upright row involves driving a bar or dumbbells up the midline of the body via an internally rotated shoulder that abducts to 90 degrees or more.
This exact motion also happens to be one of the tests we use in physical therapy — the Hawkins test — to help diagnose (or help “rule in”) shoulder impingement syndrome. When positive, pain is felt when the therapist applies pressure, ultimately grinding the rotator cuff tendons and bursa in the subacromial space.
Keeping this in mind, the upright row is a biomechanically disadvantageous motion which can directly put your clients’ shoulders at risk for developing impingement syndrome, or other damage to the joint space.
In a quest to increase the long-term health of your clients’ shoulders so they can continue to train sustainably for years to come, there are far more optimal exercises to train the shoulders which also have a lower risk of leading to breakdown.
Rebounding Box Jumps
The box jump is a highly technical movement that is designed for the development of explosive power.
So let’s get all of our clients on the box right away, right? Not so fast!
The appropriateness of the box jump should be evaluated carefully for each client as it requires many variables to be impeccably trained, coached, and executed, in order to deliver the greatest benefit, while keeping risks low, and safety levels high.
When the box jump is used for conditioning purposes, with rapid-fire “rebounding” on and off the box (for time or reps), it becomes increasingly difficult to maintain good jumping and landing mechanics, or to even be aware that good mechanics have broken down once the body starts to fatigue.
In this case, speed starts to become the only focus, above form, function and safety.
Because of all of these factors, and the ones I describe below, it is recommended to treat each jump as its own set, one at a time. Save the high rep, metabolic conditioning for lower impact, less-risky alternative exercises.
Here are the common mistakes or dangers to look out for with the box jump, followed by their fixes and alternatives:
Knees caving inward, also called genu valgum, are usually paired with excessive ankle pronation upon take-off or landing (on the box or the ground).
If this faulty pattern shows up in take-off or landing mechanics, the client is not ready to jump at all, let alone onto a raised box. Look for the causes of the issue and regress the movement. Teach proper form until they can squat with clean mechanics, even in their sleep.
Missing the Mark and Landing Square on the Shins
This happens when the client is either not ready for this exercise, or the box is too high. Serious injury to the shins, knees, or wrists from absorbing the fall can occur — don’t risk it. Lower the box, regress the movement pattern, or find a suitable alternative exercise that will achieve the same outcome.
No Hip Extension Mid-Flight
Lack of mid-flight hip extension means the knees are tucked towards the chest, which leads to landing in full knee flexion as described below.
This means the box is too high — lower it! The explosive power of the jump comes from the hip extension as you drive from the ground. If you have to sacrifice hip extension in order to clear the box, you’re missing the goal and the benefits of the entire movement. One could argue that owning powerful hip extension is essential to the longevity of the spine and knees since it is the featured movement pattern of how we lift, live, and play.
Landing on Top of the Box in Full Knee Flexion
While this displays an excellent hip flexion range of motion, this position upon landing is usually accompanied by sloppy mechanics up the kinetic chain and thus a “bleeding out” of power. It’s typically accompanied by a rounded thoracic spine, a posteriorly tucked pelvis, and excessively flexed trunk (stomach close to the quads).
Again, this signals that the box is too high and needs to be lowered. Landing on top of the box should be in a quarter-squat position, also called “athletic stance”, and should look the same as the take-off.
This position is paramount because it sets up the trunk and lower extremity mechanics, alignment, and musculature to be at the best possible position to safely absorb the force of the body onto that box. Beyond box height, failure to achieve this landing position can also be a sign of fatigue, and attempting too many reps beyond one’s capacity.
Landing Loudly on Top of the Box
Break out your cat-like reflexes! Landing softly and quietly ensures good mechanics and absorption of the compressive forces through the lower extremity musculature, and not the joints. This form is impossible to do when rebounding quickly! A good rule to remember is that jumps should be seen, but not heard.
Jumping Down off of the Box
The average client’s Achilles tendon cannot withstand the repetitive, rapid eccentric loading required to jump down from an elevated surface. Instead, stepping down backwards, to the side (lateral step down), or setting up a lower box to step onto before hitting the floor will reduce the risk of injury.
Using Rebounding for Metabolic Conditioning
When jumps are used for conditioning purposes, the rules of form and mechanics of the jump are discarded in favor of getting the feet on and off as quickly as possible. In my opinion, high reps with sloppy form, trained into and through fatigue, are inevitably a recipe for injury.
Save box jumps for power development. Use low reps, done at the appropriate height where your client can execute them with impeccable form.
For metabolic conditioning, consider using lower impact movements that contain far fewer mechanical variables that are susceptible to breakdown.
The Bottom Line
As educated trainers, coaches, and rehab pros, it’s essential to take a hard look at every exercise we prescribe from a biomechanical, kinesiological, safety, and efficacy standpoint.
Our goal should always be to optimize training to deliver the greatest result with the least compromise to safety.
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About The Author: Dr. Laura Miranda DPT, MSPT
By trade, Dr. Laura Miranda DPT, MSPT is a NYC based doctor of physical therapy, certified personal trainer, and creator of PURSUIT, the outdoor fitness movement. By mission, she empowers people on their path toward becoming the best possible version of themselves. Learn about Dr. Laura on her website DrLauraMiranda.com and follow her on Facebook, Instagram, and Twitter.