Forward by Eric Cafferty, author, and owner, of The Mecca Gym

Similar in scope to blog post #2, this paper highlights lower back injuries in competitive powerlifters specifically in the deadlift.  I have included some statistics and the prevalence of lower back injuries as well as a specific example and theoretical case study of a lower back injury.  Preventative measures should always be taken not only by elite lifters but also those lifting for health and recreation.  I have given an extensive breakdown of the deadlift technique as well as included a couple of specific exercises that can be performed to assist with keeping your lower back healthy as well as be used as a corrective exercise. 

Introduction

Powerlifting is a sport that requires countless hours of dedication and consistency. Even those who dedicate themselves to strength training spend countless hours in the gym in order to overcome physiological and genetic limitations in order to build strength and muscle mass. One of the most commonly performed movements for total body strength is the deadlift. The deadlift is also one of the three lifts performed in the sport of powerlifting. While athletes and recreational lifters alike are likely to hire a strength and conditioning professional to assist them in their pursuit of strength, injuries do occur. Injury rates were calculated to 1 injury per 1000 training hours based on a sample size of 245 competitive and elite powerlifters according to Siewe et al. Lower-level lifters appear to be at most risk for injury (Keogh, 2006). From my professional experience, I would hypothesize that injuries are perhaps more common in lower-level lifters based on less experience and less formal instruction. One of the most comely injured areas reported is the lower back. (Siewe, 2011).

There are a number of factors that can lead to injuries to the lower back when deadlifting. Reichel et al reported that most injuries in powerlifters affected the lower back at 20.5%. Deadlifting heavily involves the extensors of the spine as well as the extensors of the hips, knees, and ankles. Because of the nature of the way the deadlift is loaded into the system, heavy demands are placed on the lumbar spine to transmit the force produced by the extensors of the hips, knees, and ankles to the loaded bar. Reeves et al. reported on chronic and acute injury patterns of weightlifters and people who recreationally perform weight training. Common acute injuries of the lower back in weight training include sprains, strains, tendon avulsions, and compartment syndromes. Common chronic injuries include tendinopathy and stress injuries to the vertebrae. In addition, muscle hypertrophy, poor technique, or overuse can contribute to nerve injuries (Reeves, 1998)

After completing a rigorous training session, a recreational lifter complains of lower back pain. The lifter experienced a slight pinch or shift in the lower lumbar spine mid-repetition during the last set but it was not painful enough to stop mid-set. 

Movement Breakdown

The lifter in question has not had any previous injuries however they commonly experience what they describe as excessive soreness in their lumbar spine. The lifter reports that after nearly every deadlift session the extensors of the lumbar area are sorer than the extensors of the hip. Placed under increased load or volume, this can lead to injury over time. Whether it be from one incident or a chronic overuse injury where the spinal erectors are over-taxed.

Links to a side, front and rear video with the correct deadlift form can be seen here:

Side:https://dartfi.sh/BtFOpxmkc8b

Front:https://dartfi.sh/Wgq5OL9Uue4

Rear:https://dartfi.sh/WFRR6cDUVqk

Common improper deadlift form involves beginning the lift with a rounded lumbar spine. A video demonstrating this can be seen here:https://dartfi.sh/Za62URc6RC5

All Key Positions

Key Positions (see side view dartfish videohttps://dartfi.sh/BtFOpxmkc8b):

Initiation of concentric movement.

At the initiation of the concentric phase of the movement, the subject is seen as “Breaking the floor” as it is often termed. During this phase, the subject is heavily focused on engaging the latissimus doors and bracing the axial skeleton with intra-abdominal pressure. This phase involves an isometric contraction of the muscles of the axial skeleton to prevent rounding of the bar and thoracic spine. Since the load is attached to the system from the arms, the abdomen and thorax are used as a lever between the glenohumeral joint and the coxal joint. The extensors of the hip contract to extend the hip in the sagittal plane simultaneous to the extensors of the knee contracting to extend the knee in the sagittal plane. Working as co-contractors these two muscle groups work synergistically to stand the subject upright with complete hip extension and complete knee extension.

Initiation of knee extension.

In most lifters, we will see the knee joint extend first and at a faster rate toward the beginning of the motion in order for the lifter to move the bar perpendicular to the floor. Extending the knee at a faster rate allows the subject to avoid friction with the anterior leg, patella, and quadriceps. Once the bar crosses the patella the subject will decrease the rate of knee extension and increase the rate of hip extension.

Table 2 Knee Extension

Initiation of hip extension.

The extensors of the hip are the primary movers of the deadlift. These muscles should be contracted throughout the duration of the lift. They rely upon most when the bar is moving above the patella to pull the hips forward and hinge the bar up to its end range of motion. It is common such as in the improper deadlift example for a lifter to utilize the extensors of the spine to compensate for weak hip extensors. This can lead to immediate injury such as a disk herniation or more commonly a chronic overuse injury of the spinal extensor muscles.

End of concentric movement.

At the end of the concentric phase of the movement, the subject is seen standing in full hip and knee extension. The extensors of the hip and the extensors of the knee are isometrically contracted in full extension. Being in full extension at the hip and the knee allows the athlete to maintain an erect position holding the bar on the anterior surface of the thigh. Full extension of the knee, full extension of the hip, and glenohumeral joint being in a straight line above both the knee and hip joint constitute the completion of the concentric portion of the movement. The spine should be held in a neutral position throughout the movement (see Tables 1,2 &3). The difference in the muscle function compared to the first phases of this movement are all muscles are functioning in an isometric contraction.

Knees unlock and hip flexion begins.

The hip flexion rate should be faster than the knee flexion rate at the beginning of the eccentric phase of the deadlift. This allows the subject to keep the bar tracking in a linear and perpendicular line to the floor as well as preventing the bar from excessive friction on the anterior surface of the leg. It also prevents the bar from intersecting with the distal portion of the quad and the patella which can cause injury. The coxal joint is the main pivot point of the movement. As seen in the incorrect video, the subject begins the eccentric phase rounding the back which places dangerous stress on the vertebral disks. 

Table 4. Hip Flexion

Rate of knee flexion increases.

Just as the rate of knee extension in the concentric phase of the movement, the knee flexion should increase in the eccentric phase. This allows the bar to travel in a linear perpendicular line to the floor, maximizing the deadlift’s efficiency. This also prevents the subject from rotating the pelvis out of a neutral position as the bar travels to the floor. 

Table 5. Knee Flexion

End of eccentric movement.

In position three the subject is seen at the completion of the repetition. This position should look identical to position one. During the eccentric phase of the movement extensors of the hip and extensors of the knee are lengthening and performing an eccentric contraction in order to control the load back to its initial position seen in position one and position three. The eccentric phase of the movement begins with flexion in the hip controlled by lengthening of the hip extensors. Immediately after the following flexion at the hip joint, knee flexion occurs controlled by an eccentric contraction of the extensors of the knee. The Flexors of the hip and flexors of the knee are involved but not primary movers of this motion. For example, the illiacus and psoas are contracted but not controlling the flexion of the hip because the flexion of the hip is caused by the load of the bar on the system. 

Key Positions (see rear view dartfish video https://dartfi.sh/WFRR6cDUVqk):

Initiation of external rotation at the coxal joint

One deadlift phase commonly overlooked is the external rotation at the coxal joint. This external rotation assists with the activation of the hip extensors and keep the knee joint tracking in the correct pattern. External rotation opposes the activation of the adductors during the deadlift which if not opposed will cause the knees to cave in putting the knee joint at risk for injury and preventing the complete activation of the hip extensors.

Chart 6. External Rotation of the Coxal Joint

Key Position (see side view dartfish video  https://dartfi.sh/BtFOpxmkc8b):

Dorsiflexion and Plantar Flexion at the ankle joint.

When performing the deadlift the subject must dorsiflex to get into the proper starting position.  The subject then plantar flexes the ankle joint as the movement is initiated so that the force transmitted through the coxal and knee joint stands the subject up while maintaining balance.

Chart 7 Plantar Flexion of the Ankle Joint

Discussion

One common error in the deadlift is when the lifter has kyphosis or lordosis at any point in the movement.  Lordosis is most common at the end of the concentric phase of the movement.  During position two all isometric muscle contractions are preventing movement in the sagittal plane.  As seen in the incorrect example video this injury was caused by an intrinsic factor, which means it was an error made by the subject. 

While it is common for extrinsic factors to occur, intrinsic factors are harder to control.  Factors such as proper warm-up, state of recovery, and movement pattern or form are common sources of injury (Baechle, 2008).  This particular injury has two main causal factors to consider.  The first factor is technique.  In the incorrect video, you can see the subject has a rounded lumbar and thoracic spine from the beginning of the movement to the end of the concentric phase and from the beginning of the eccentric phase to the end of the eccentric phase.  This places the spine in a very vulnerable position and has a high likelihood of causing a strain or sprain as well as a disk injury.  This is a horrible technique.  The technique can be an easy fix and it starts by reducing loads and hiring a strength and conditioning professional to give the proper cues and demonstrations.  From there it is up to the lifter to practice the movement and relearn the proper motor pattern.  The next big factor in the lifter’s control is strengthening different areas of the body so that each segment can tolerate the loads being placed on it.   In this particular example, it is very possible that the muscles of the abdomen, pelvic floor, and lower posterior chain are deficient compared to the muscles of the spine and the extensors of the knee.  This is causing this athlete to manipulate his body to utilize the stronger muscles and use the improper technique. 

This leads me to my movement recommendations and exercises prescription for corrective exercises.

Exercise Prescription:

The first step to take with any injury is to step back and assess the area in question.  I’m this case we have pain in the lunar spine.  Even though it was caused by an incident during one training session it is possible that the injury was also caused by performing this exercise incorrectly over a long period of time, leaving the subject more vulnerable to injury because of a worsening imbalance.  Once the subject utilizes the RICE (rest, ice, compress and elevate) technique a more accurate assessment can be made and corrective exercises can be utilized.  After a formal assessment, we determine that the athlete needs better cueing, instruction, and corrective exercise to remedy the imbalance that has formed and strengthen the areas of weakness.

It is also a recommendation to implement a stretching and mobility protocol to put the athlete in a better starting position.  Common problem areas when it comes to mobility and the deadlift are the hamstrings.  The hamstrings are a limiter of anterior pelvic tilt and this will limit the athlete’s ability to assume a position with a neutral spine at the starting position of the deadlift.  This will cause the lumbar spine to be in a flexed position from the starting position, therefore, putting the lumbar spine in a lordotic position and preventing a correct movement pattern. 

Once the athlete has implemented the RICE technique and the inflammation has reduced, I would recommend he start with exercises to help strengthen his weak areas.  We determined that his spinal erectors need corrective exercise to stabilize correctly in the deadlift and that his obliques and gluteal muscles are weak in comparison with other muscle groups involved.  Two exercises to build strength and encourage the healing process are the bird-dog and barbell hip thrust.

Exercise 1: The bird-dog

This exercise is intended to provide active stability on the trunk and is provided by co-contraction of the muscles present (Leporace, 2010).  This exercise takes place on all fours with your hands directly below the same side glenohumeral joints and the knees directly below the same side coxal joints.  The subject is instructed to pull the navel into the spine and keep the pelvis and spine in a neutral position.  The glenohumeral joints and coxal joints should stay level throughout the motion.  The muscles of the spine should stay isometrically contracted thought out the movement.  The subject then reaches the foot and the hand of the opposite arm and leg up and out extending the hip and the shoulder reaching as far apart as possible.  The subject then returns to the starting position and repeats with the opposite sides.  A common mistake of this exercise is extending the spine which involves dropping the ribs towards the floor and moving the pelvis in an anterior as well as tilting the coxal joint of the active side up or down or tilting the active glenohumeral joint up or down.  This exercise can be done as frequently as daily for 3-4 sets of 10 to 30 repetitions.  A link to a demonstration of this exercise can be found here: https://dartfi.sh/2HvGIqCrwX8

Exercise 2: Hip Thrust: https://dartfi.sh/sMCcmfWwLk5

This exercise begins seated on the ground with an exercise bench directly behind the subject.  The barbell is rolled into the crease of the hip so that it can rest directly above the coxal joints at the end of the concentric phase of the movement.  The feet are pulled back towards the gluteals so that when at the end of the concentric phase the knees can be at a roughly 90-degree angle.  The subject will engage the bar with the hips with the edge of the bench resting mid-scapula.  The subject will keep the chin tucked towards the chest and the navel pulled in bracing the abdominals.  At the initiation of the movement, the subject will extend the hips to full extension and move the bar perpendicular to the floor to the end of the concentric phase.  The subject should be applying force through the mid-foot throughout the movement.  Common mistakes include not bracing the core which can diminish benefits such as sacroiliac joint stabilization (Added, M. A. N., 2018).   This exercise can be performed as often and 5 days a week with a recommendation of 3 days per week at 3-5 sets of 6-20 repetitions.  A link to a demonstration of this exercise can be found here: https://dartfi.sh/sMCcmfWwLk5

If the subject experiences pain in the injured area during one of these exercises it should be stopped immediately and the load and technique should be evaluated.  If pain persists the exercise should be stopped altogether.   Those exercises will supplement a strength training program and encourage rehabilitation while helping prevent weakness in the abdomen, spine, and hip extensors. 

References

Added, M. A. N., de Freitas, D. G., Kasawara, K. T., Martin, R. L., & Fukuda, T. Y. (2018). Strengthening the Gluteus Maximus in Subjects with Sacroiliac Dysfunction. International Journal of Sports Physical Therapy, 13(1), 114–120. Retrieved from http://search.ebscohost.com.cucproxy.cuchicago.edu/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s8419239&db=s3h&AN=128335094&site=ehost-live

Baechle, T. R., & Earle, R. W. (2008). Essentials of strength training and conditioning: Human kinetics.

Biel, A. (2014). Trail Guide to the Body (5th ed., pp. 275-342). Boulder, CO: Books of Discovery.

Leporace, G., Praxedes, J., Metsavaht, L., Pinto, S., Chagas, D., Pereira, G., & Batista, L. A. (2010). Muscular Synergism during Core Stability Exercises. International Symposium on Biomechanics in Sports: Conference Proceedings Archive, 28, 1–4. Retrieved from http://search.ebscohost.com.cucproxy.cuchicago.edu/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s8419239&db=s3h&AN=59696268&site=ehost-live

Keogh, J., Hume, P., & Pearson, S. (2006). Retrospective injury epidemiology of one hundred one competitive Oceania powerlifters: The effects of age, body mass, competitive standard, and gender. The Journal of Strength & Conditioning Research, 20(3), pp.672-681.

Reeves RK, Laskowski ER, Smith J. Weight training injuries: part 1: diagnosing and managing acute conditions.  Phys Sportsmed. 1998;  26 67-96

Reeves RK, Laskowski ER, Smith J. Weight training injuries: part 2: diagnosing and managing chronic conditions.  Phys Sportsmed. 1998;  26 54-73

Reichel, T., Mitnacht M., Fenwick, A., Meffert, R., Hoos, O., Fehske, K. (2019). Incidence and characteristics of acute and overuse injuries in elite powerlifters. Cogent Medicine, 6(1), 1588192. https://doi.org/10.1080/2331205X.2019.1588192

SELKOWITZ, D. M., BENECK, G. J., & POWERS, C. M. (2016). Comparison of Electromyographic Activity of the Superior and Inferior Portions of the Gluteus Maximus Muscle During Common Therapeutic Exercises. Journal of Orthopaedic & Sports Physical Therapy, 46(9), 794–799. Retrieved from http://search.ebscohost.com.cucproxy.cuchicago.edu/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s8419239&db=s3h&AN=117941196&site=ehost-live

Siewe J., Rudat J., Röllinghoff M., U. J. Schlegel U. J., P. Eysel P., J. W.-P. Michael W.-P. (2011) Injuries and Overuse Syndromes in Powerlifting. Int J Sports Med; 32(9): 703-711 DOI: 10.1055/s-0031-1277207.  https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0031-1277207

Vera-Garcia, F. J., Barbado, D., & Moya, M. (2014). Trunk stabilization exercises for healthy individuals. / Exercícios de estabilização do tronco para indivíduos saudáveis. Brazilian Journal of Kineanthropometry & Human Performance, 16(2), 200–211. Retrieved from http://search.ebscohost.com.cucproxy.cuchicago.edu/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s8419239&db=s3h&AN=94808073&site=ehost-live

Yoon, T.-L., Cynn, H.-S., Choi, S.-A., Choi, W.-J., & Lee, J.-H. (2014). Asymmetrical trunk muscle activities and kinematics during dominant and nondominant leg lift in subjects with lumbar rotation with flexion syndrome. Isokinetics & Exercise Science, 22(2), 145–151. Retrieved from http://search.ebscohost.com.cucproxy.cuchicago.edu/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s8419239&db=s3h&AN=96204382&site=ehost-live