Is Corrective Exercise Necessary?
“If we wait until we’re ready, we’ll be waiting for the rest of our lives, let’s go”
Yes, I did just quote Lemony Snicket, which turns out isn’t even the authors real name, it’s David Handler, which is actually quite irrelevant to my message.
This is about the proliferation of corrective exercises. It’s about how trainers are taking clients and trying to make them perfect before exercising which is not only frustrating for both parties but also an unnecessary time killer.
In my recent article on Nick Tumminello’s site I went over what I considered corrective exercise to be. I think it’s easy to identify but hard to create a clear cut definition of what it is. So for the sake of this article I’ll repeat it:
“When I think corrective exercise, I’m not thinking about things that are addressed with good coaching, nor am I thinking of simply using basic exercise regressions. When I think “corrective exercise” I’m referring to special exercises coaches prescribe after an assessment procedure in attempt to “fix” (i.e. correct) what they deem are specific “dysfunctions” displayed by the client.
Now, I’m not completely discounting corrective exercise – it has its place. My main concern and message is its overuse where simply basic exercise training concepts would be more effective, not to mention the lack of evidence that supports many of claims that drive corrective exercise prescription. I also have concerns on the lack of definable lines that we can draw on where and what “dysfunction” actually is. The problem is if there isn’t a real problem and trainers spend time addressing this “boogeyman” problem that doesn’t exist.”
Nick does a good job explaining it here:
Then finally here are some examples of what I would consider corrective exercise:
For trainers to prescribe corrective exercises they have to be of the opinion that there is an actual problem. Unfortunately, most of the problems trainers identify are just nonexistent boogeyman problems including:
- Postural problems and the correctives that come along with it
- Mobility /movement issues
- Breathing patterns (note: I do think this is important for a higher performance weight lifter. I have a friend working with me on my breathing but I feel as if this issue shouldn’t be addressed before some type of performance is gain although I’m sure it can be argued the other way.) I’m going to have a part two here where my friend Brandon Nurnburger goes over his thought process on when to teach breathing drills.
Most client problems are caused by the lack of movement so to remedy the situation the trainer should provide movement rather than 30 minutes of corrective exercises. Before I get into my main points I’ll share a quick example.
I had a client come in to me with knee pain; here is her lunge pattern.
I knew she wasn’t going to be a performance client so I just focused on moving more and moving ‘better’ (at least in the context of the gym) if there is such a thing. Low and behold, three weeks later she was in less knee pain. Movement had prevailed!
Postural problems and the correctives that come along with it
In order for us to think that posture is a problem three things need to be true- (1) poor posture causes pain and (2) poor posture can be used as a predictive tool for injury and (3) poor posture affects muscular performance.
I’ve identified the definition of ideal posture before here, but here it is again as defined by Kendall and McCreary “a vertical line passing through the lobe of the ear, the seventh cervical vertebra, the acromial process, the greater trochanter, just anterior to the midline of the knee and slightly anterior to the lateral malleolus” (1)
According to a biomechanical model low back pain is caused by musculoskeletal dysfunction which can be evaluated by looking at how spinal curves deviate from Kendall and McCreary’s ideal posture. These ‘abnormalities include kyphosis and lordosis and well as pelvic tilt (2). As for an injury predictive tool, “in this model, the imbalances and asymmetries increase the abnormal mechanical/physical stresses imposed on the musculoskeletal system. This may lead to recurrent injury or the development of chronic conditions through a gradual process of wear-and tear” (3).
So, many people would tell you that not only is your posture causing you pain but if you don’t fix it you will get worse. Not only that, but if you have bad posture and you’re not in pain you probably will be. I’ve been on the other side of a few assessments where I was told my leg length is off, which is irrelevant (3) and that my bicep will explode (yes explode) if I didn’t fix problems with my current alignment.
There have been a multitude of studies discounting pelvic tilt and lumbar curvature as a prospective cause of low back pain. One study looking at different types of movement that elicited low back pain found that there was no significant difference in lumbar curves for subjects with and without low back pain. They did find that “(a) both men and women in the Rotation Extension (type of movement that elicited pain) had more lordosis than their counterparts in the Rotation Flexion category, (b) both men and women in the rotation flexion category had less lordosis than their counterparts in the rotation extension category” (4) So they found differences in movement related pain and spinal curves (different groups in pain had different lumbar curves) but no significant difference between those with pain and those without. Other studies and reviews have found similar results. Pelvic inclination and low back pain are not as linked as we have been told (5-8).
One review attempted to connect the dots between anterior pelvic tilt and possible implications for prevention of sports hernias and osteitis pubis (9). The author states that “conditions specific to athletes that have a relationship to pelvic imbalance are osteitis pubis and sports hernias/athletic pubalgia” (9). He describes Janda’s classic lower body cross syndrome as being caused by a weakness of the abdominals and hamstrings crossed with a tightness of the hip flexors and erectors. He cites a study on abdominal length and tilt to support his cross syndrome theory that in fact directly contradicts what his claim is on the cause of hip muscle imbalance (10).
I don’t pretend to be an expert on injury prediction and as for prevention don’t typically look at the pelvis. Furthermore, visual assessment of pelvic position is poor at best (11). I find movement is a better indicator or ‘dysfunction’ whatever that means than static alignment.
As for upper body alignment, I’ve recently added a piece on that to the site which you can find here. It focuses mainly on neck alignment.
Lots of fitness professionals look at scapular position as a potential risk factor for impingement syndrome. The idea here is that impingement is caused by changes in scapular position as well as with increases in thoracic kyphosis.
“These changes are thought to produce a compressive impingement under the acrmion, creating a mechanical block to elevation of the humerus and irritation of the subacromial tissues” (12). As such, corrective exercises have been utilized to return the scapula to its ‘normal’ position. People with impingement have “demonstrated decreased upward rotation, decreased posterior tipping, and increased internal rotation of the scapula during arm elevation” (13). As such these movement patterns would be addressed by strengthening specific muscles (serratus and lower and middle traps) and stretching other muscles (pectoralis minor).
However, in a recent review in the British Journal of Sports Medicine the authors concluded that, “non-surgical treatment involving rehabilitation of the scapula to an idealised normal posture is currently not supported by the available literature” (14). A further review from the Journal of Strength and Conditioning Research quotes PT Shirley Sahrmann who says that “the most common cause of abducted-rotated scapular position is shortness of the scapular abductors and is associated with excessive length of the scapular retractors. Treatment includes improving scapular retraction and stretching pectoralis major and minor” (15). This presumes that muscle length and strength dictate scapular position.
However, muscular strength affecting scapular position is not supported by the literature. DiVeta et al found no significant relationship between scapular position and middle trapezius force, pec minor force and ratio of muscle forces. Length on the other hand was linked to position. The review stated that stretching the abductors may be more important than strengthening the adductors (15).
Even if scapular position is identified as ‘abnormal’ who says it actually is a problem. Take me for example, (and I know N=1) but I have ‘poor’ scapular control with no pain or limits on performance.
Can we deem this dysfunctional? Can this be used as an evaluative tool? Perhaps, but I’m not completely sold like I once was. However, in terms of sports and high performance athlete’s postural asymmetries and imbalances may increase the likliehood for pain (3).
So quick recap, posture is not associated with pain and cannot be used as a predictive tool for pain. As mentioned in the last paragraph, perhaps it can play a part in high performance athletes. So what about strength? I recall an old T-nation article where Mike Robertson states that:
“What goes on at your pelvis seriously affects what goes on throughout the rest of your body. Do you have a huge lordosis and anterior pelvic tilt? If so, you’re losing pounds on all your lower body lifts because you don’t have appropriate glute involvement. “
“Optimal pelvic alignment means better posture, optimal muscle recruitment, better lifts, and better health” (16)
Unfortunately, there is nothing in the literature to support how pelvic position plays a role in strength. Believe me I’ve looked (MEDLINE & SPORTSDISCUS) and asked around as well. Furthermore, as mentioned above the literature does not support any strength imbalances as being a cause for a certain pelvic position. Anterior pelvic tilt and lumbar lordosis are not one in the same either! (10).
Lastly, you get into the issue of whether or not you can or should actually change posture, which is beyond the scope of this post but here’s a good read from Paul Ingraham if you’re interested.
Mobility /movement issues
What about movement or mobility issues? If we don’t need to worry too much about correcting posture then surely we should be fixing mobility and movement issues. The answer is that it depends. ‘Good’ movement isn’t such a narrow scope as we make it out to be and I personally don’t even like the word good, followed by movement. Of course, watching professional athletes move should impress most people but should a red flag be raised because a client can’t move like a professional athlete? Todd Hargrove had a nice post on the topic here which does a great job of expressing exactly what I mean.
So what do you mean by it depends?
I would certainly correct valgus collapse on a squat and I would probably address people who have ‘quad dominant’ movement patterns like the client in the first video. Research shows that the quadriceps act as ACL antagonist and the hamstrings act as stress shielders to the ACL (17) and it’s been well established that valgus collapse under load or when landing can contribute to an ACL injury. There’s also a whole host of movements that when performed poorly under load should be addressed.
However, quote on quote acceptable movement isn’t as narrow as some professionals would have you believe. Let’s take my friend Colin, for instance, he has a great squat. Now just because I cannot squat as ‘well’ (whatever that means in this instance) as Colin does it mean I’m destined to be injured and weak? I think not.
Not every client is going to be the smoothest mover out there but rather than trying to make them perfect I propose working within the clients current capacities with minimal corrective exercise. If a client cannot perform a dumbbell hinge or deadlift, that’s not the end of the world. There are plenty of other alternatives like a glute bridge. If their squat isn’t spot on a Bulgarian split squats or reverse lunges are just fine. Time would be better spent on exercise as opposed to hip and thoracic spine mobility drills. Work with what you have rather than what you want to have.
The Functional Movement Screen attempts to say pain and injury can be caused by poor movement. Gray Cook is noted for saying “don’t add performance on top of dysfunctional movement patterns,” which is great advice. You wouldn’t load up a squat for someone that doesn’t know how to squat. At least I hope not! I agree with a lot of what he says in that we should be striving for high quality movement. It’s just hard to define what high quality movement is for each specific scenario, when does it become detrimental to performance, and when does it become, if it does become a valid predictor for injury? For the most part the research shows very mixed reviews on movement as a tool for injury prediction. This can be read about here, it’s got enough references to keep you busy for a few days!.
Since the next part is in progress let’s wrap it up with my thoughts:
I share similar thought process to Nick in the first video above. Try general exercise first. Corrective exercise might have some merit but I’m not sure if it is a tool trainers need to use. It might be better left to therapist.
This part will be coming later once Brandon has sent me his input on the topic. Thanks for reading, drop a comment below on what you think about the subject!
(1) Griegel-Morris P., Larson K., Mueller-Klaus K., Oatis C. A. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their associations with pain in two age groups of healthy subjects. Journal of the American Physical Therapy Association. 1992; 425-431
(2) Nieuwenhuyse A., Crombez G., Burdorf A., Verbeke G., Masschelein R., Moens ZG. Mairiaux P., Physical characteristics of the back are not predictive of low back pain in healthy workers: A prospective study. BMC Musculoskeletal Disorders. 2009
(3) Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. Journal Of Bodywork & Movement Therapies. 15(2):131-138, 2011
(4) Norton B, Sahrmann S, Van Dillen L. Differences in measurements of lumbar curvature related to gender and low back pain. Journal Of Orthopaedic & Sports Physical Therapy. 34(9):524-534, 2004
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(9) Waryasz. G. R. Exercise strategies to prevent the development of the anterior pelvic tilt: Implications for possible prevention of sports hernias and osteitis pubis. Strength and Conditioning Journal 32: 56-65, 2010
(10) Walker ML, Rothstein JM, Finucane SD, and Lamb RL. Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Phys Ther 67: 512-516, 1987
(11)Fedorak C., Ashworth N., Marshall J., Paull H. Reliability of the visual assessment of cervical and lumbar lordosis: how good are we? Spine (Phila Pa 1976) 15;28: 1857-9, 2003
(12)Lewis J., Wright C., Green A. Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Journal of Orthopaedic & Sports Physical Therapy. 35: 72-87, 2005
(13)Borstad J, Ludewig P. The Effect of Long Versus Short Pectoralis Minor Resting Length on Scapular Kinematics in Healthy Individuals. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. April 2005;35(4):227.
(14)Ratcliffe E., Pickering S., McLean S., Lewis J. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. British Journal of Sports Medicine. 2013
(15) Hrysomallis C. Effectivness of strengthening and stretching exercises for the postural correction of abducted scapulae: A review. Journal of Strength and Conditioning Research. 2010; 567-574
(17)Boden B. P., Griffin L. Y., Garrett W.E. Etiology and prevention of non contact ACL injuries. The Physician and Sportsmedicine. 28: 2000