Do You Screen For Injury Risk In Training?
The first tenet of training is to do no harm to your client. While most coaches and trainers shrug off this golden rule of fitness, many professionals in our industry truly don’t fully understand nor appreciate the depth of importance of the “do no harm” credo.
Just because your clients aren’t herniating discs with ugly rounded back deadlifts or tearing their rotator cuffs to shreds on the bench press while under your professional supervision doesn’t mean that your programming and coaching isn’t predisposing them to aches, pains and injuries down the line.
Sure, it’s easy to self-justify “safe and effective” training practices when your clients aren’t dropping like flies to the gym floor with acute traumatic training induced injuries. But the question remains, is your coaching, programming and management helping your clients achieve physical resilience and longevity?
This is absolutely a loaded question, and one of the most difficult for coaches in our industry to answer definitively. Step back, put your ego aside and honestly ask yourself this question; is your training doing more harm than good? But here’s the more important question… how do you even know?
Instead of just hoping and praying that your clients stay healthy in training and throughout their other physical endeavors in sport and life, we need to start placing some objective measures on training risk management. We screen and assess our clients in order to identify red flag issues, set baseline levels of function and create professional standards and goals to work towards in training.
But as cloudy as the movement screening landscape may seem, initial screening processes to mitigate major training related injuries don’t have to be overly complicated. Here are three of the simplest, yet most effective ways to implement a standard screening process for your clients in order to ensure training safety for the spine and shoulders which comprise a vast majority of both acute and chronic training related injuries.
The Deep Squat Hold
The third world squat is one of the best all-around positions for quickly and effectively screening many joint and soft-tissue positions at once. This bodyweight deep squat position and hold places a heavy emphasis on how someone tolerates end range spinal and lower extremity positions while also challenging motor control (the way the body coordinates multiple segments together synergistically in space) in a gravity dependent position on two feet. Specifically we can assess pain, dysfunction and movement capacity in the following joints and regions:
- Cervical spine flexion
- Shoulder protraction and internal rotation
- Thoracic spine flexion
- Lumbar Spine flexion
- Posterior pelvic tilting
- Hip flexion and external rotation
- Knee flexion
- Ankle dorsiflexion
As you can see, that’s quite the list of end range joint positions that is yielded by this one movement. With so much to look at, we implement the deep squat screen into our initial client intakes along with hitting this position at least once in a dynamic preparation sequence before training to re-assess positions and pain-provocation before each training day.
For complete screening of this position, we can challenge the active joints and encompassing soft-tissue regions by extending the end range hold. Instruct your client do get down into as deep of a squat as possible, allow the body to round forward and to hold this position for 30 seconds.
During the hold, it is your job as a coach or practitioner to continuously assess the joint positions from the list above bilaterally for symmetry, but also to monitor changes in positions throughout the 30-second duration of the hold. Sinking deeper into the squat is considered normal, but unilateral compensation patterns would be considered a data point that you’d most likely address in training.
Ensure that you have open lines of communication during the hold, as non-painful positions may turn painful while extending the hold time in these positions. Instruct your clients to “talk you through” what they are feeling, as their internal neurological response and proprioception is a far better indicator of pain or dysfunction than even the best coach’s eye could ever be.
After 30 seconds of yielding data from both positional changes and pain-provocations, instruct your client to simply move slowly into a kneeling position then stand back up. We do NOT want them to stand up out of this position in a screening scenario, as we are not testing the squat, but rather the components of a true deep squat pattern.
The screening of the deep squat position lines up well with a prediction of success for both the squat and single leg patterns, and being able to challenge these patterns with intensity and loading. If this screen creates pain or highlights asymmetries or dysfunction, use your professional judgment in prescribing loaded movements for the squat and lunge, and ensure that you have an active strategy moving forward to improve these more problematic positions.
The Standing Toe Touch
While the deep squat hold is a complete way to assess end range flexion based joint capacity throughout many of the key functional players in the body, the one thing that the squat position lacks is assessing spinal position and pain provocation based responses from a more of a neural tensioned position in the lower extremities.
It should come to no surprise to hear that lower back pain is the second most common (behind shoulder pain and injury) injury site among the active population. But the lumbar spine is more than just bony vertebral segments and the soft-tissues that insert upon it. It’s the home of a vast neural network of wiring that exits the spinal column and travels throughout the lower extremities to control and coordinate both motor control and sensation into the hips, legs and feet.
The traditional toe touch test is by no means revolutionary in terms of screening a client’s flexibility, but when you break down it’s components, it shows far more than just the ability of the hamstrings to elongate in a standing position. This movement quickly and efficiently offers one of the most complete outlooks on neural tension, spinal positioning and lumbo-pelvic motor control of any functional screen out there, making it a requisite for any complete screening process.
Proper setup and screening instructions for this movement is imperative to ensure the data that is yielded from the screen is both reliable and useful to prioritize and properly program a training plan accordingly.
- With shoes removed, place both feet together.
- Extend the knees to a fully straightened position.
- With one hand placed over the other reach down and attempt to touch the floor directly in front of your toes.
- Make sure you allow your clients to fully flex to achieve their end range.
- Once end range has been achieved hold for a full second.
- Rise back to the neutral starting position.
For quality and reliability purposes, make sure that you test a minimum of three reps, as one rep does not give a proper representation of one’s true motor or pain response abilities. As we say, anyone can have severe pain OR be an absolute all-star on one single rep.
When screening this toe touch, we are not only assessing if the client indeed was able to touch their fingertips to the floor in front of them while maintaining a straight knee position bilaterally, but also the quality of the movement itself, which many times is the more important factor for injury risk mitigation.
The quality metrics that you will be assessing throughout the toe touch are:
- Lumbo-pelvic rhythm
- Posterior hip shift
- Even distribution of flexion moments throughout the spine
Lumbo-pelvic rhythm can simply be thought of as the sequencing of the lower back moving into a flexed position while the pelvic smoothly moves into a posterior (backwards) tilted position until end range is met. While this rhythm is happening, there should also be a posterior hip shift of the hip moving backwards as the spine and upper body continue to flex forward.
Finally, there should be an even distribution of flexion range of motion coming from all segments. What this essentially breaks down to is the lack of a “fulcrum” point in the spine, which is a segment or two where a vast majority of the flexion range seems to be coming from. Remember, we are looking at the entire spine (head to tailbone) as a unit here when screening quality flexion moments and a potential fulcrum point in the range.
Maybe the most important aspect of this screen is the pain-provocation aspect of this sometimes-exacerbating position. As your client moves to touch the toes on the descent, AND while they move back up to return to position from the one-second end range hold, we need to be assessing for pain responses. Of course lead by asking your client “do you have pain during any part of this movement?” and follow up your question by being a savvy coach with good instincts.
While it’s a great starting point to ask your clients if they have pain in any movement (most importantly in the the screening process) we must also use our eyes and ears to assess pain-responses that are not verbally reported. Keep a close eye on these types of presentations:
- Facial grimacing
- Tense flexor muscles
- Highly active secondary respiratory muscles (neck and shoulders)
- Jerky uncontrolled movements
- Holding breath – general alteration of breathing patterns
The toe touch screen transfers very nicely into prediction of safety and skill with the hip hinge based movement pattern like the traditional deadlift. If one has pain during the toe touch, especially neurological pain (traveling, severe or unilateral) during this movement, ensure that you are programming a pain-free hip hinge alternative that is well tolerated while improving the movement quality long term. If no pain is present, but limitations present in any of the objective findings of the screen, adjust your loaded hip hinge patterns to fit their current movement capacity, and work on a complete strategy to improve movement quantity and quality for the dynamic warm up and cool down periods.
The Prone Press Up
While the previous two screens looked at both the capacity and pain response of the spine and neighboring regions moving into flexion, there is a huge need to also screen the opposite global movement pattern, extension, to gain a more global understanding of movement abilities linking to risk mitigation in training.
Though there are many extension based movements out there that screen the spine moving from neutral-ish position into extension based moment, the key focus of this article is how to yield as much information about your client as possible in a minimal amount of time invested in the screening process. With this in mind, the prone press up is a superior option to look at the lower and upper body segments inclusively in one single movement screen.
While lying down on the stomach in the prone position, we allow the body to reduce relative apprehension levels by simply increasing the amount of support and ground contact that the body has on the floor. This increased surface area contact of the body to the ground reduces the need for huge amounts of motor control, balance and coordinated proprioception that can sometimes cause a “neural lock” of movement patterns that diminishes the ability to grade true joint and soft-tissue capacity.
While assessing in a motor control rich environment is equally as important as reducing motor control and screening, we have already looked at global movements with high requite motor control in the previous two screens, making this third and final screen one that is more dependent on end range flexion that’s not being held back by regional muscular tone or tightness.
Ensure that we position this screen correctly again to objectify reliable findings in both pain and asymmetrical dysfunction:
- Lay face down on the ground.
- Position your knees straight and toes pointing down (plantarflexion).
- Place your hands under your shoulders.
- Press up by extending the elbows and extending the neck and back.
- Hold the end range press up position for 1-second.
- Control the movement back down to the chest on ground.
While it’s clear that we are assessing the spine moving into extension from this position, we also get some valuable insight into the following regions as well:
- Cervical spine extension
- Thoracic spine extension
- Lumbar spine extension
- Packed shoulder position stability
- Anterior pelvic tilt
- Hip extension
- Knee extension
- Ankle plantarflexion
You’ll notice that this list includes many of the opposite joint and soft tissue positional directions as the deep squat screen, and that’s done strategically to have a better understanding of full range of motion from flexion into extension in as many joints and regions as possible.
For every screening procedure you bring your clients through, the first focus should almost always be placed on the way the spine moves and stabilizes. When in doubt, place a laser focus in on the movement quality, quantity and pain provocation patterns of the spine, as this is the most central an integral portion of the kinetic chain that has the ability to affect so many other regions, movements and functions.
With that in mind, here are the key metrics that we are looking at for the prone press up in addition to the clear “can you press yourself all the way up with elbows locked in” which is usually the only pass/fail objective measure that is traditionally used with this screen:
- Spine extends with even distribution of range from each segment.
- Hips extend past neural position (less than fist width off of floor).
- Pelvic anteriorly tilts to unlock extension potential at spine.
- Top of feet remain in contact with ground.
- No unilateral rotation or shifting present.
In terms of pain-provocation, this screening position is most useful for finding extension-based intolerances at the lumbar spine. These types of presentations show up as pain at the lower back or sacro-iliac (SI) region upon press up. But in addition to pain at the lumbo-pelvic region, we also need to be assessing the ability of the shoulders to bear loading in a packed and centrated position as the press up reaches end range. Make sure you are asking your client if they have pain during this movement, including ANY site on the body, and not just the lower back.
This screen is a powerful indicator of one’s ability to display pain-free capacity with heavier bracing (things like squats, deadlifts and carries) along with more dynamic effort movements like Olympic lifting, sprinting and sport specific field work. Though there has been more talk about the dangers of spinal flexion in training and sport, we need to place an equal emphasis on spinal extension intolerances as well to ensure safety no matter the physical endeavor.
Program according to your findings, and let objective data lead your client and athlete management from day one instead of playing a guessing game every time a client gets under load. That is how we start to program smarter to train harder and safer simultaneously.
About The Author
Dr. John Rusin is an internationally recognized coach, physical therapist, speaker, and sports performance expert. Dr. John has coached some of the world’s most elite athletes, including multiple Gold Medalist Olympians, NFL All-Pros, MLB All-Stars, Professional Bodybuilders, World-Record Holding Powerlifters, National Level Olympic Lifters and All-World IronMan Triathletes.
Dr. Rusin is the leading pioneer in the fitness and sports performance industries in intelligent pain-free performance programming that achieves world class results while preventing injuries in the process. Dr. John’s methods are showcased in his 12-Week FHT Program that combines the best from athletic performance training, powerlifting, bodybuilding and preventative therapy to produce world-class results without pain and injuries.