Episode #378: Bulletproof or Broken- Why 'Perfect Form' Is a Lie

25:09Derek Miles would say. So I just think it's an interesting way the public kind of views these things, really opposite of how they are. But I agree. We should not be demonizing activities. Speaking of demonized activities, we do have to talk about the elephant in the room, CrossFit. I mean, we have been critical about the actual programming of CrossFit's workouts as far as do these things fit an individual's goals. But the reputation that it's gotten is that it's a meat grinder, and we've got to fact check that. Everyone assumes that if you do high rep snatches or you do these Metcons or whatever that you're going to explode.

25:47But, Austin, does the data actually support the idea that CrossFit is uniquely dangerous compared to something like powerlifting or weightlifting? Yeah, honestly, not really. And this is borne out by several studies and metas that have been done over the years. I know that there was some publication and even some legal wrangling around this stuff over the past 15 years or so. But to some extent, we also run into similar definitional challenges. On one hand, we have the challenges of defining injury. Here, we also have the challenge of defining what CrossFit is and then kind of integrating those two things to decide, like what are we even talking about, what counts here.

26:23And honestly, I don't think that there's any, even though CrossFit is a unique brand that got super popular, it seems to be relatively less so at this point compared with the past. It's something that is a form of exercise that just like as, I guess we're kind of cutting to the chase here a little bit, like any other that we talk about, it has to do with the balance of what is the stimulus and the stress of what you're trying to do compared with the level of stimulus or stress that you are prepared to tolerate. And so based on some of those studies that have looked at it, their injury rates between two to three-ish injuries per thousand participation hours.

26:56Now, I suspect that if we looked and scrutinized that data super closely, there would probably be a relatively broad range, you know, kind of around those like, you know, averages that were determined from each of those studies because CrossFit can look like so many different things, right? And you have such a broad demographic that actually took it up and engaged it. But that range, if you'll recall, is pretty similar to what we cited for powerlifting injury rates, weightlifting injury rates, things like that. But if you're talking about a beginner just getting into it versus if you're talking to a competitive CrossFit Games athlete versus a weekend warrior CrossFit athlete who doesn't do anything during the week and then goes in for the hero wad on the weekends, like these are all very different contexts to be looking at and I suspect would relate to different levels of injury risk.

27:40Yeah, in fact, so a number of the studies have actually looked at people at a CrossFit gym and doing CrossFit programming as prescribed by that gym. And I think most people would sign off. That's probably CrossFit. And there does seem to be a signal in novices that people who are new to CrossFit do seem to have a higher rate, somewhere around nine, for about the first eight weeks. To me, and you can weigh in on this, that seems like mostly like a load management thing. Either people are really excited or the dosing of exercise that's being given to them is just something they're unprepared for.

28:13it's not that the exercises selected or the way that the workouts are programmed themselves are inherently bad it's just that they're dosed inappropriately for these relatively untrained individuals they're not kind of fit for that that test does that seem right to you yeah i think i'm throwing this back to our friend greg lehman uh here again who said something to the effect of you know exercise preparation trumps exercise quality or might have been movement preparation trumps movement quality so being prepared for the thing you're trying to do is what's most important. And then even when you're maximally prepared, there's obviously still some risk of fluke things happening, especially if it's in a contact setting.

28:50But the lack of preparation going into it, combined with maybe the nature of the programming, and then the exacerbation of, I don't know if they're still playing like dubstep music overhead and having a social environment and people yelling and trap slapping and, and encouraging each other to push potentially even further beyond what they're ready for. So that is, you know, a reasonable way to explain this kind of early observation. If people had a more clear, I mean, I know that there are plenty of gyms out there that have this sort of on-ramp type program where they do aim to prepare people more thoroughly for these types of things.

29:23And then potentially the way that their introductory programming goes can also be used to mitigate some of this risk would be my hypothesis. Yeah, yeah. Initial sessions at RP8 versus RP10. That competitive environment can be not only addictive from like a social setting thing, which is probably good for like participation, but if you're pushing to failure too often, particularly too soon, if you're not ready for it, yeah, I mean, kind of a recipe for what you see here. And there's also a slightly increased risk of rhabdomyolysis, which is something we've talked about on this podcast a number of times.

29:55And again, I think that's mostly from the competitive setting, also potentially some heat stress. If you're in a warehouse and it's not really well ventilated AC, that sort of thing. And the duration, because a lot of classes by default are an hour. And so again, if you're a beginner and you're getting into this and you're not habitually used to exertion for an hour, then that's a way, you know, but if we restricted you early on and said your first workout is going to be, you know, 10 or 15 minutes max, uh, obviously the shorter the workout is the, the more intensity you might tolerate. But if you jump into an hour session and like most of it is at least moderate, if not high intensity for that time, lack of preparation.

30:28Yeah. You're going to end up, you know, with the more severe case of a delayed onset muscle soreness that we call rhabdo. Yeah. Yeah, there you go. All right. Now there's one final disconnect that we need to fix. So when influencers talk about injuries, they typically describe them like car crashes. If you round your back, your disc is going to explode. If your knee caves, you're going to tear a meniscus. They paint a picture of acute catastrophic failure. But when we actually look at the epidemiology of lifting injuries, that doesn't really match reality. Sure. In contact sports like football or soccer, yes, you can see acute trauma.

31:00Someone tackles you, bone breaks, Yeah, that's the car crash. But in the gym, the vast majority of injuries are chronic overuse injuries. It's tendinopathy. It's a muscle strain. It's a nagging ache that developed over three weeks because you increased volume too fast. And so the available data actually shows that the average symptom duration for injuries from exercise, specifically resistance training, is less than two weeks. if they were catastrophic structural failures, blown discs, torn ligaments, people would be out for six to 12 months. You know, they would need surgery. They need some sort of medical intervention, but these things tend to resolve in less than two weeks without seeing a doctor, which suggests that these are largely fatigue related issues and not structural explosions.

31:43Get rid of the mushroom cloud, get rid of the red line. It seems to be more of an overuse chronic thing or fatigue mediated injury. Is that the way you understand this stuff? That reflects most of our experience, myself doing consults and working with people in this setting, as well as our rehab team, the vast majority of the time, you know, we start out our conversations, tell me, you know, how'd you end up here? Tell me your story. And then it ends up being, oh, I got this ache or this pain here. And I think back to what my training looked like and, you know, started to come on during this period of time.

32:11And then it got exacerbated because of this and gradually progressed anyway. And it usually is a, what we'll call at least subacute to potentially even chronic type syndrome. Certainly some things, everything starts suddenly at some point, right? It's just a matter of how severe it is at onset that often motivates people to seek care more quickly or to like tolerate it, work through it, work around it for longer periods of time. But a huge proportion of what we deal with are the little bit more nagging, persistent type issues. And the more acute ones, they tend to either declare themselves as obviously catastrophic up front, as rare as those are, those tend to be much more apparent right away when they're, you know, to that degree.

32:48and if they're not in that category, then they tend to be ones that actually get better quite quickly, interestingly. Yeah, to me, all this fear-mongering about sheer forces and micro-tears is treating a deadlift with a rounded back like it could be a car wreck, but in reality, the risk profile is much more like getting a blister. If you hike too far in new boots, you can get a blister. It hurts, you change your shoes, that's load management here, and then it heals and you go on hiking. You don't need surgery for a blister and you don't need to be terrified of hiking. You just need to break the boots in slower next time.

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34:29We've established that lifting is safe, but people do get hurt. And when they do get hurt, they can get an MRI sometimes or a CT or other sort of advanced imaging. They see a bulging disc or a meniscus tear and they think, ah, I found the smoking gun. I found the pain generator. I am broken. Now, Austin, over the years, you've pulled some incredible data on asymptomatic populations. These are people who have like terrible MRIs or abnormal findings, but zero pain. So why is an MRI often a liar when it comes to pain here? Yeah, super interesting and super complex topic. I do think the MRI is put up on a pedestal as like this diagnostic gold standard to the extent that it even has a nickname name that we often joke about calling it the answer donut because it's a circular shaped machine that you end up kind of getting rolled through to acquire the images.

35:17And we know, for example, from the world of back pain data looking at how common it is to find abnormalities, quote unquote, in people's spines who have no back pain. There is admittedly also evidence showing that, well, that might be true, but also people who do have back pain, they might have a slightly higher incidence of some of these findings as well, which is not terribly surprising. But the fact that it is possible to have no symptoms and to have a significant, a really quite high prevalence of certain findings like bulging discs, for example, in upwards of 80, 90 % of people once they get to a certain age in life, even if they have no pain, is just, it's an interesting observation that should make us pause and reconsider our overall understanding of this topic.

35:58Maybe there is more to this thing that we call a pain experience than just what is going on in the tissues from a visualizable medical imaging standpoint. The other conclusion that I draw from these type of data is also that because pain is a more complex experience, it also means that we can often help people get better even if we do not normalize, quote unquote, your imaging. So if we had to repeat an MRI, if we absolutely needed all the imaging findings to resolve to go away in order for your symptoms to get better, man, I would feel for rehab professionals. They would have a tough job ahead of them to pull that off, right?

36:35But fortunately, we know they get people better all the time, even when their imaging does not necessarily change. We know that a fair amount of these things that we see on imaging are either completely incidental, accidental things that were not pertinent to anything that the person might have felt or might not have felt, or are age-related in the same way that we expect to see people across the lifespan acquire more wrinkles in their skin or more gray hairs and things like that. That's completely unsurprising. we also acquire these things on the inside of our bodies on our imaging tests like mris and ct scans and then lastly it could be actually evidence of sport specific adaptations which is the really interesting one for folks who are unfamiliar with it so for example if you take major league baseball pitchers who obviously throw most of the time with one arm for the duration of their career lots and lots and lots of high velocity high force throws that's their entire job and you scan their shoulders, even when they have no pain, basically 100 % of them have abnormalities in that shoulder that is being used to its maximum capacity day in and day out.

37:40Not no pain, no disability, no dysfunction. It's just the fact that the tissue is being used and stressed in a way. It's almost like imagine somebody who, you know, has trained their whole life and they have achieved a significant amount of muscle mass growth or muscle hypertrophy, right? It's an adaptation, right? If we called that an abnormality, like, oh, you're growing these weird, you know, contractile tumors in your skeleton, right? Pathologizing that, calling it a problem when it actually, it's an adaptation. So we see the same thing in pitchers, differences in the arms of tennis players who use one arm, or I imagine like bowlers or anybody who uses an extremity, I suspect in legs and knees of basketball players who are jumping of soccer players, or probably, you know, NFL kickers, all of these things that are used and stressed and adapt, they will end up showing abnormalities.

38:27The problem is it's also the case that many of these athletes are in sports where they are pushed and maybe beyond their capacity or might be a contact sport and maybe they do develop pain in an area and then you scan them and you find one of these things that might have been there all along anyway the challenge comes to how do i interpret this how do i explain it to the person right and then how do i actually aim to rehabilitate them do i feel like i have to act on this imaging finding or what are the odds that this imaging finding was one of these either age-related things or incidental things or it was an adaptation but the athlete is at risk of saying, oh no, like my career is over because I have this thing on my MRI when really it's just like, nah, it's because you're really good at what you do.

39:08Yeah, there's a fine line between an adaptive response and a pathological response. And the sort of line in the sand between the two really comes down to the dosing, which we call like load management. So if the dose, if the total training load is something that the person can tolerate, and recover from, then they're likely to get an adaptive response. And you might see things on MRIs. You might see vertebral end plate thickening in weightlifters, ACL hypertrophy in weightlifters, for example, the dominant arm, the serving arm in a tennis player is growing longer. You might see these hot spots of active tissue remodeling, abnormalities on imaging that are actually going to be a feature, not a bug.

39:56But if the dosing is too high, if the load management is improper, then that can shift to the other side of the line, which is pathology at that point. And so we need to talk about load management. And we'll use another analogy here that actually kind of works, in my opinion. I'll get your take on this. We're going to talk about the body like a bank account. So your tissue's capacity is like your bank account balance. And the workout is a withdrawal. You have$1 ,000 in the bank. That's your capacity. and you try to withdraw$1 ,200, that's the load, you can get an overdraft fee, which would be like an injury or pain or sort of pathological response.

40:32Now, the foreign police think that the overdraft happened because you swiped the card with your left hand instead of your right hand. That's technique. We think the overdraft happened because you spent too much too fast. You can spend or lift with, quote, bad form, a weird swipe all day long if the transaction is small enough,$5. But the reason that we can increase the budget is because unlike a car, we are adaptable. This is the sort of death of this wear and tear body is a machine myth. So I thought this other analogy that you might like is this callous versus brake pad. We do all this car stuff, right?

41:07So if you drive your car every day, the brake pads get used every day. They get thinner until they wear out and they break, right? But if you rub your skin, like with the barbell every day, it doesn't get thinner until it breaks. In fact, it gets thicker. You You develop a callus. And like I said, weightlifters have larger ACLs and denser bones. These are adaptive responses. They are not pathological responses. But pop science and influencers treat your discs and knees like brake pads. We treat them like calluses. You need to stress the body appropriately with the right dose to build this armor.

41:42The only danger is rubbing so hard that you get a blister, that's too much too soon, before the callus form. Hey, it's Jordan here cutting in from the editor's desk. Now, we just talked about the bank account analogy and building a callus instead of a blister. Conceptually, that's great, but the hard part is actually finding the, quote, right dose of stress in the gym so that you get stronger without the overdraft fees. Now, you might be thinking, okay, how do I actually audit my training fatigue? How do I know if my technique is efficient? What do I actually do in the gym? And that's why we created the Injury Risk Action Plan to be more than just a triage for pain.

42:14It's a toolkit for performance over the long term. It's not a textbook. it's five actionable tools that you can use today. The first one is the fatigue audit. It's a literal ledger to check if you're overdrawn on training stress. Number two is the rep model. And there's also a big three checklist. These are rapid fire ways to dial in your form without overthinking it. We have the dosage navigator to customize your progression plan depending on where you're at in training. And yes, there's an injury triage protocol. It's a decision tree for exactly what to do if you feel a pop or an ache in the gym.

42:44Now, whether you're currently dealing with a tweak or you just want to train productively for years to come, this packet is the blueprint. It's free, it's in the show notes, download it, save the checklist to your phone, and let's get back to the episode. How do you like those analogies? I quite like those. I've not used them before with patients, but perhaps I'll selectively deploy them when needed to help somebody understand some of these concepts, especially, you know, I oftentimes, when doing a consult with somebody, I'll ask them to explain to me, you know, what they think is going on and what led them to me.

43:15and I'll just shut up and listen to their story. And I've had people talk for upwards of an hour, just unloading all of their thoughts and fears and beliefs and expectations and everything. And so that's the situation where it ends up being a lot of work to kind of help them unlearn things that are unhelpful for them and get them redirected in a useful direction. And these types of analogies can sometimes be useful when deployed, I think, in a tactful way with the right person. So I'm with you, I like it. All right, cool. Well, so now that we know the mechanism, this sort of load exceeding the capacity, people still want to blame a specific boogeyman.

43:48So we're going to line up the usual suspects here and see if they're actually guilty. Starting with suspect number one, heavyweight. You ask a random person why people get hurt in the gym, the number one answer is they're lifting too heavy. Logic is simple. 100-pound squat is safe, but a 500-pound squat, well, that's dangerous. Austin, does the data actually show that lifting heavier weights increases injury rates? Yeah, this is going to be a tough one for people because their intuition on this is going to feel so strong. And so I think that there's going to be some degree of what is your own experience compared with what are the data?

44:22And then we're going to have to come up with some way to reconcile this. Because I like setting out up front, what would I predict if this were true? This is often how it informs lots of our interactions and arguments when we get on threats. If this were true, what would you expect? And then what is the data that actually looks at it in that way tend to show? So if we expected that the higher intensity, higher load lifting caused dramatically higher injury rates, then we would expect that the competitive powerlifters and weightlifters would have the highest injury risk, that bodybuilders and other folks who train with relatively lower loads would have much lower levels of injury risk.

44:55And that doesn't actually tend to be the case based on the data that we cited earlier. CrossFit, also, they tend to use very different absolute loads and even relative loads compared to their one rep max compared to some of these athletes. and we actually saw not a higher incidence in the group that was tending to lift with higher loads. But we saw a pattern that suggested more of this, are you adequately prepared for the thing that you're trying to do? I know that you have cited before some data on strongman as an interesting kind of, I don't know, you can call it an outlier compared to some of these other sports.

45:26What are your thoughts on strongman? Yeah, Malcolm Gladwell, take your shirt off. Yeah, strongman and Highland Games tend to be these two outlier sort of resistance training or strength sports that do tend to have higher injury rates than that two to four injury, two to four injuries per thousand participation hours that we talked about. Strongman somewhere like 4.5 to six, something like that. And then Highland Games is like eight. But interestingly, the lighter competitors who lift lighter loads actually had higher injury rates than the heavyweights who lifted heavier loads. And to the extent that it was known, most of the injuries came from awkward implements.

46:01So like stones, yokes, et cetera. Now, I'm doing a little bit of rationalization here. Like, why would that be the case? But I do think it's likely that the reason why that most of the injuries came from the awkward implements being used is just due to lack of preparation, relatively speaking. Most strongman athletes come from bodybuilding or powerlifting or whatever, Olympic weightlifting, some sort of barbell sport-based background. and they're very well trained and adapted to those things, which are relatively sterile compared to, hey, pick this rock up and like do some stuff with it or like these other implements that they may not have exposure to in their training because what do you mean?

46:41You don't have fingal fingers in your gym. You don't have an Apollon's wheel, like whatever. So yeah, I thought that was interesting. It's like there is a signal there. And how do we explain that? That said, if it was just load alone, just heavy weights. Yes, to your point, you would expect the heavyweight strongman athletes to have more injuries because they're lifting heavier, but that is not the case. What's your verdict on this overall? Is this suspect number one guilty or innocent? I think that this is we have presented a case that makes it unlikely to be the primary suspect, meaning I'm moving it down on my tier.

47:15It's almost like in clinical medicine when I build a differential diagnosis, I don't ever tend to take diagnoses completely off the table but rather shuffle their probability as a contributor. So I'm just moving this way down on my list of concerns in general for people, particularly if they're well prepared for what they're trying to do. The absolute load is not the thing that gives me the greatest source of concern. Yeah. All right, let's move on to suspect number two. This has to do with like exercise selection and a quote orthopedic cost. This is somewhat related to suspect number one. might be his cousin, right?

47:47Because the thought is that heavy compound lifts like squats, bench press, deadlifts, well, they're expensive. They cost you joint health, whatever that means. So should we swap them for cheaper exercises like split squats or trap bar deadlifts to save the athlete's joints? Is this a valid way to view training? Are we spending our joints when we lift heavy? I have always found this argument not terribly convincing. I think that this again ties back into those very mechanical views of the body, viewing it as a machine with a really limited lifespan or mileage, so to speak, or how many reps that you could ever tolerate in your life.

48:25And it really tends to assume that, hey, just because you do this particular movement, that it is going to cause some degree of damage that you can never recover from. And this fails to recognize the key concept that we've been laying out repeatedly so far is this idea of adaptability. but in particular adaptability to an appropriate stress. And so I think that that's where this comes in. Now, you will hear certainly anecdotally and you'll hear probably from a lot of people who are among Mike Boyle's audience, the types of people who he might be preaching to, they might validate some of this with their own anecdotes and say, yeah, well, when I do this, I tend to get pain.

49:02And so to that, my questions would still be to interrogate a little bit more about their training history because we know, for example, that what's the greatest risk factor for having an injury is a prior injury. And so if you have a history of tweaking your back doing this, there might be the case that you, compared to somebody who's never experienced it, you might be a little higher risk. That might be an area that has some sensitivity on a longer term that might need to be addressed or managed. And then aside from that, yeah, what are you trying to do? And then tell me about your preparation to do that very thing.

49:30Now, nobody has to squat or has to deadlift. But we also know that a lot of these movements are kind of key components of everyday life in one way or another. And so having the capacity to do it, I think is important for pretty much everyone. The necessity of training it and training it maximally or heavy, I don't think that either of us, you know, insist upon that broadly speaking for the population. And so then there's a degree of, you know, discussing the person's preferences, but none of this, when it comes to prescription ties back to the idea of, oh, you are either a person in general who needs to be worried about orthopedic costs, or more often this is like you are above a certain age.

50:05And so this becomes a more unique concern for you. So how do you tend to reframe this concept? Yeah, I mean, I think, again, it ignores adaptation. Like, when you drive your car, your tires don't get thicker, your brake pads don't get thicker, right? But the body does do that in response to an appropriately dosed sort of stress. And so I kind of flip this thing on its head. You know, instead of like, oh, it's a heavy cost to do a deadlift, I think it's an investment. Yeah, the stress can potentially be high depending on reps, intensity, proximity to failure, et cetera. But the ROI is that your bones get denser.

50:41That's Wolf's law. Your tendons and ligaments, they grow. That's Davis's law. We know that the human body adapts to these things if it's dosed appropriately. Now, of course, there's a role for machines, dumbbells, et cetera, due to preferences. People prefer to do those things. And even it might be the preferred movement outside of personal preferences from my standpoint. If I have a person who, yeah, I can put a bar on their back or whatever and they can squat, but it's really – they don't have a good opportunity to train it. They're just not coordinated enough yet to do it. There might be some mobility restrictions.

51:16I don't need to force that as a primary means of getting stronger, gaining muscle mass, gaining function, right? I can use a leg press. That doesn't mean I don't want them to squat at some point, and they may do it as a practice sort of thing or just like a general mobility exercise, like a general warmup. I've done all of that. But the leg press is the bread and butter for actually improving function of the lower extremity muscles. And so, yeah, I kind of flip this thing on its head. I view it more as an investment than a cost, and, yeah, you can get a pretty good ROI. So my verdict on this is that exercise selection, orthopedic cost, again, lower on the differential as far as the primary cause.

51:54I'm saying innocent. The burden of proof has not been met yet. Agree. All right. Suspect number three, we're talking about hyper-specialization. We've established that orthopedic cost, while made up, not really a scientific term, probably not the most likely cause here of injuries. Your knees don't have a finite number of bends before they expire. but there is a kernel of truth here when it comes to exercise selection. If I only do low bar back squats, same stance, same shoes, same tempo, etc. for five years straight, is that a risk factor for injury? Is the problem the exercise or is the problem more of hyper specialization?

52:31Yeah, there's an important distinction to be made there. The idea from the orthopedic cost discussion is that that movement itself is the problem, That is the thing that we should vilify, that we should avoid at all costs to avoid incurring that cost. But what we observe in practice and through our own experience and even looking at some of the evidence on this, that when we have this state of what you described as hyper-specialization, meaning your training looks relatively monotonous, there is what we call low movement variability. You do the same thing day in and day out, repeatedly, say multiple times a week, and oftentimes maybe a little bit too heavy as well or with too many overall working reps or something like that.

53:09that is a different way of stressing the body and when it is that repeated then that certainly is a common pathway that leads to these types of aches and pains that i call kind of subacute to chronic these smoldering things that develop that we just categorize as generalized overuse syndromes and it can be quite difficult to help somebody kind of dig their way back out of that hole particularly if they're for some reason very emotionally attached to that particular exercise or if that is their primary sport and they feel like the more i do this thing the better i'm going to be at this thing kind of reminds me of some of the discussions we had years ago when that book, I think it was range that came out in terms of specialization versus kind of delaying specialization and building a broader base up front and the outcomes that tend to emerge from that across various disciplines.

53:56And so we tend to, when working with folks in this situation, broaden out that variation and rather than keeping them kind of locked into a single repeated movement pattern. And we always make the clear distinction that it is not that this movement is bad. It is that the cumulative dosage that you are being exposed to by doing this and only this too much too often is the thing that we need to modify. And people tend to do great when we address that. Yeah. It's not about avoiding the squat because it's like expensive, uniquely expensive. It's just that you've got to vary the stress a little bit.

54:26So for a person who's not a competitive powerlifter going to a meet, well, let me back up. For a person who's not a competitive powerlifter, like you don't need to squat with a bar on your back. You don't need to bench press with the barbell. You don't need a deadlift from the floor. I think all of those exercises are fine choices if you like them, but we don't need to compromise your training so much that all of your lower body movements are either a squat or deadlift variation. All of your upper body movements are a bench press variation. You don't need to specialize that much. And even for my powerlifting clients, I don't do that for the majority of their training year.

54:59It's the lead up to the meet. So what do you do instead? Well, there are many different ways to hinge. For example, you can deadlift. You can hip thrust, for example. You could do both sumo and conventional. You could do single leg stuff. For a squat pattern, you could squat certainly with a bar on your back. You can do split squats, unilateral stuff. You can do a leg press, God forbid. You can do body weight work, calisthenic-based stuff. All of this stuff can work to improve muscular strength, to increase muscular hypertrophy, to increase general muscular function. So my advice, especially for people who are not barbell sport athletes, very close to a competition where you do want to specialize is build a broad base of physical development.

55:44Get good at everything, right? And then if you need to or want to specialize later on, great. So we can use a car analogy here this time that actually works. If you drive your car for 50 ,000 miles without ever rotating the tires, the tread will wear out on one specific spot until it blows or cords or does something. Now, the problem wasn't driving the squat. The problem was you kept the pressure on the exact same square inch of rubber for too long. Variation rotates the tires. It spreads the stress across the entire system so that no single spot fails. So exercise selection matters, not because some exercises are, quote, bad, but because doing the same exercise over and over again increases the risk of an overuse injury, especially if the dose is too high.

56:26Do you agree with that? I guess I'll allow it. You'll allow it. All right. The judge allowed it. Verdict for this particular suspect is innocent. So now we have to move on to the next suspect. Suspect number four, this is going to be speed or velocity. So people look at, like, Olympic weightlifting or CrossFit, and they see people moving barbells very quickly. It looks chaotic to the casual person. It looks like Snap City, if they know what Snap City is or where it is. The assumption is that moving slowly like a bodybuilder is safer. Is this based in evidence, Austin? I would challenge people to once again think like a scientist here and say, if this hypothesis were true and I compared athletes across certain sports, higher velocity like, say, weightlifting versus powerlifting, which is low velocity, then I would expect the weightlifters to have a massively higher rate of injury risk.

57:17And then when we look at actual evidence that has examined this, doesn't seem to support that fear. We end up seeing relatively similar injury rates between these two disciplines as well as many others that are on the average a bit faster compared with those that are a bit slower. And again, this comes back to this idea of what are you prepared to do? To what task are you most adapted? And so for people who train with speed, with ballistic movements, with explosiveness, they tend to adapt and get better and better at doing that. Now, we have talked about this before, for example, when we get questions about somebody who wants to get into sprinting, because they have heard maybe of some particular benefits of sprinting.

57:54And one of the things we tend to tell them is, hey, if you've never sprinted before, going out to a flat track and doing, you know, 10 rounds of 100 meter sprints, I have some degree of apprehension, perhaps about how your hamstrings are going to tolerate that effort. You might do okay, but there are probably ways that we can alter that stress to mitigate that risk and help you better prepare to do that thing that you're trying to do. And so we might reduce the overall number of sprints and we might put somebody on an uphill, for example, to mitigate some of those risks to address that issue until they are ready to handle that degree of speed and explosiveness and power generation.

58:29And then we can kind of unleash them in a different environment and we actually don't have the same degree of concern anymore. So it is not intrinsic to that task, but the context has changed in terms of this person's level of preparation for that speed and explosiveness and the same thing applies to slower activities somebody says i've never you know done a one rep max deadlift before and so suddenly i'm going to do a one rep max deadlift attempt that is you know 100 pounds in excess of my all-time best lift or something like that i'm gonna say maybe don't love how aggressive we're about to be here it's going to be slow and so maybe like well i you know slow velocity it should be safe and it's like yeah it's going to be quite slow how how prepared are you to do this thing, right?

59:10How close have we gotten to this effort in our training to date? And that's something that we can probably aim to work up to a little bit more progressively rather than jumping all the way up. So the speed itself here is not the variable that leads to our source of concern, but rather what led up to that effort. Yeah, I think we should exonerate speed from the charges. We'll move on to our next suspect. I promise I'm not gonna keep this legal thing going for much longer, we're getting to the end. But suspect number five has gotta be age. Now, this one is my favorite of the entire podcast, mainly because I just turned 40, you know, and actually got a notice from the age police that I could no longer lift heavy.

59:44They said, look, you can't actually deadlift over 600 anymore. You can't certainly squat that much. It's just you're too old. Be careful. You're not 20 anymore. But the data actually shows an inverse trend here. So multiple studies have shown that younger lifters, so those under the age of 30, actually have higher injury rates than older lifters. There's a few other data sets that make the cut point at 40, which I found very convenient for me. And so when I'm interpreting this data, the data is what it is, right? And so now we have to explain, well, why is this the case? Now, this is some speculation certainly, but I think this is mostly behavioral, that younger lifters may be more prone to increase the training load too quickly, right?

1:00:26They have less experience. Their training age, if you compare somebody who started training at 20 and now they're 25 compared to somebody who started training at 20 and now they're 40, The training age is much different. This old man strength thing is kind of real, right? There's just more experience. There's a little more maturity and more experience with auto-regulation, even if you don't call it auto-regulation. You go through your warm-ups. You feel, ah, the weight isn't moving quite as well as I wanted it today. I'm going to have to adjust. Even if you don't use RPE, reps in reserve, bar velocity, any of that stuff, you just know it because, again, you've been doing it for so long.

1:00:58That said, the callus has been built up over a long period of time. It is very thick and robust. And so even if there's an error, perhaps there's some protection there. But I don't think that older generally makes people more fragile. It just makes you more experienced. It may actually be protective factor in the gym from those behavioral sort of things here. The possible caveat here is that older folks who are untrained, I'm talking about individuals in their 60s and 70s, they have a lower fitness level. They've been inactive for longer. We generally have to be a little more careful with them when we start their training.

1:01:32And that's mostly from a training load standpoint. And that's because their current fitness is lower. But that would be the same if somebody who was 20 years old, who for whatever other reason, had a low level of fitness too. So it's not an age-related thing. It's mostly a fitness-related thing. It just happens to be that most older folks who have previously been inactive, they tend to have a lower fitness level. But that's not really age-related. It's more just a habit thing that we see in society. Totally. I mean, I can think of multiple examples. obviously this is getting a bit into the clinical realm but some of the patients that i've seen some of the sickest you know young people who unfortunately had a bad case of some cancer or another you know they're in their 20s or 30s and just horrible luck really sad cases sometimes and this person is you know skin and bones super thin super weak super frail and we're trying to get them up and move around and if i was to put myself in a situation where i want to decide how to like program this person to build some fitness i'm going to be quite cautious with them off the bat, whereas somebody who might be double or even triple their age might be able to tolerate much higher amounts of training, no problem, if they've been much healthier and active throughout their life in general.

1:02:39This reminds me of the stat you cited at the very beginning when we were comparing across different sports in the context of running in particular, where novice runners had the much higher rate of injury, and then the more experienced and elite runners who are doing way more running volume in general, especially at high levels of running performance. I mean, these folks are, you know, running well over a hundred mile weeks a lot of the time, but the more experienced runners actually tend to have tended to have the lower injury rates probably because of the accumulated base of fitness that allows them to better tolerate and to match the dose of what they're doing to what they're, what they've prepared for compared with the novice athlete in general.

1:03:12Yeah. But because we bring the nuance here, there is a little wrinkle, I think here that we should probably address. There's some sort of survivorship bias, survival bias, just amongst elite lifters in general or elite athletes in general. I mean, you see the same relationship between elite Olympic weightlifters and those who are either at the national level or regional level, there's a higher injury risk at the lower level than the higher level. And you're like, well, look, they're lifting heavier weights. They're doing more training load. Why aren't they as injured? It's like, well, look, something got them there.

1:03:40And whether there's genetic components, behavioral components, other sort of intangible things that reduce injury risk that allow somebody to like reach their full potential and be an international level or elite level athlete, there's something at play there. But I don't think that age is, you know, a causal sort of risk factor here. And so, again, I'm giving it – I'm innocent. Innocent until proven otherwise. Do you agree? Yeah. I mean, older folks, you just need to prepare for what you're trying to do. And that seems to – I'm going to keep hammering that throughout this episode. Yeah, I'm embracing old man strength.

1:04:11All right. A couple more suspects left. This is a fun one, anabolics. So far we've debunked a few things, but there's one major factor that does seem to spike injury risk, although not sure how causal this is. The industry doesn't like to talk about it. Anabolic steroids. So to me, I'm going to take on this. It's tricky to kind of separate the signal from the noise. When you look at data here, yes, just by and large, there are more injuries in individuals who use anabolic steroids than don't. And this can be at super physiological doses. So people are legitimately taking high doses. But it also happens in individuals getting TRT.

1:04:49And you're like, wait, what? But to me, though, when I look at this, it looks like a mismatch problem. So steroids, generally speaking, and not like glucocorticoids, not those steroids you get to tamp down inflammation, for example, or deal with an autoimmune disease. But anabolic steroids make the muscles stronger very quickly. But the adaption rate, adaptation rate of those compared to tendons and ligaments, which are much slower, that's a mismatch. It's like putting a Ferrari engine in a Honda Civic. The engine, your muscle, produces so much force that the chassis of the Civic, no hate comms to a Honda Civic, it literally is mismatched.

1:05:27So my verdict on this, get your take on it, is guilty-ish in that it does seem to be a unique risk factor, particularly at super physiological, super therapeutic doses. But it's not because the steroids themselves do something to the tendon, to the ligament, to the joint that makes it more vulnerable. It just makes people much stronger compared to the adaptation rate of the soft tissues. And there may be some additional motivation from like, I'm on, I'm on here right now. I should increase weight to maximize my gains. Yeah, I find it plausible. This is not an area of like massive expertise for me, but I find it plausible that, you know, we keep talking about this idea of like, are you prepared to do the thing you're trying to do?

1:06:07Whereas in this situation, what it ends up coming down to is these let you do things that you're not prepared for. Right. And so I can see a scenario where somebody might be using these substances, but with, again, proper progression and load management of their training, being more cautious with that over time, recognizing that, oh, this is about to let me do things that I'm not maybe fully ready for, or I might be able to do this before I should do this, to use Dr. Derek Miles' line of can I do this versus should I do this, that might lead to this issue that you're describing. Yeah. All right.

1:06:41So I'm going to give it a guilty-ish, but it has some accomplices. All right. Sure. Suspect number seven is going to be accidents. This is the last one. We spent all this time arguing about biomechanics and sheer forces, but actually a huge chunk of gym injuries have nothing to do with lifting at all. We call these gravity events. And so you look at ER data. So a study of emergency room visits showed that 77 % of injuries in kids in the gym were just from dropping weights on their feet or pinching their fingers. Now, a lot of gym injuries aren't because they rounded their back during a deadlift.

1:07:15They probably weren't even deadlifting, but they just tripped over a dumbbell, didn't use a collar and the plate slid off, et cetera. When you look at older individuals, older cohorts, it represents a smaller subset of injuries, somewhere around 20%, depending on who you read and where they got the data from. But still, the gym is a physical place with heavy metal objects that can fall on you and can injure you. so i'm gonna say that accidents are guilty i kind of view this as like a luck sort of thing like yeah sure sometimes it do be like that yeah yeah i don't know have you ever i know that both of us have had some experience with dropping stuff on ourselves none bad enough that it led to something catastrophic that required medical attention or you know going to the er or anything but here and there i've definitely like stubbed my toe on a rack or you know dropped a i think a 25 which fortunately did not lead to a broken toe i don't think i've ever dropped a 45 or a 25 kilo plate on myself, but, um, I suspect you've had some similar experiences.

1:08:07Yeah. I mean, I've stubbed my toe. I smashed my finger between plates before I've, you know, lacerated various things by getting caught in things in the gym that I'm like, Oh, ergonomically, that doesn't make much sense to me. Yeah. But like that, again, it's just a subset of injuries that occur in the gym. And again, tend to happen in younger people. So again, shout out, shout out to old man strength on this one. Yeah. All right. So look, if weight, exercise selection, speed, movement, speed, and age aren't the main culprits, well, everyone from there is going to pivot to the holy grail technique.

1:08:39You got hurt because your form broke down. Now, if you ask most coaches, you ask most people why they got hurt, they'll say, well, look, I moved wrong. My form broke down. It's basically the ultimate scapegoat. But Austin, when we actually look at the scientific literature on this, is there even an agreed upon definition of what, quote, good technique actually is? Yeah. Much like definitions of injury or definitions of what, quote unquote good posture is there is not clear consensus on this and i think that we've talked about this at seminars before where you've cited this 2009 systematic review that defined proper technique and i'll just pause for dramatic effect here as performing exercise that maximizes adaptations and minimizes injury risk which is kind of a worthless definition right it's like yeah we want an exercise that gives us the good stuff and none of the bad stuff and we'll call that good a good exercise so it's pretty circular definition um uh that that ends up not being terribly useful when it comes to application or identifying you know what might be quote unquote good technique or bad technique because you can only really determine it retrospectively but even then it doesn't mean that the person exercised good technique if you're going to have something because it's possible to do an exercise and move in all sorts of ways with a movement technique that by and large we might not consider ideal and to not get injured from it.

1:09:55So that it did not cause an injury does not necessarily imply that it was good. So it's kind of a useless circular definition that we don't actually tend to use in our practice. What do you think? Yeah, I agree. It seems like a tautology to me. It's just like, oh, look, you perform an exercise and you got some gains from it, but you didn't hurt yourself. The technique was good. It's like, are you sure about that? Yeah. And it is interesting to me that only one study actually has taken a stab at this despite everybody talking about good technique, perfect technique. It's the way to really mitigate your injury risk.

1:10:29So maybe it's like a Justice Potter thing, you know, to go back to the legal stuff. We know bad technique when we see it. And so we assume that, quote, good technique means looking like a robot, that every rep looks identical down to the millimeter. And if you deviate from that robotic path, well, that's an error. Austin, does the data support the idea that elite lifters move like robots? Yeah, this gets back to the mechanical kind of model of movement and exercise technique and things like that. And this is super intuitive to people. You will see all the time, for example, people in the lifting space who say, your goal should be to make every single rep look as identical as possible.

1:11:09And it's like, it sounds good, and it's a reasonable hypothesis, But if we actually look at how people move, even at a very high level of sport, it tends to not actually be that way. So there's this concept called dynamic systems theory that we've actually talked about. This was now years ago, I think, when we last talked about this topic of movement variation. But the idea here is that there's this relationship between the person, their body, their psychology, their movement patterning and things like that. There's the environment that they're in and there is what is the actual task that they're trying to do?

1:11:42And in particular, what are the unique constraints of that task? So one simple example could be if you are trying to back squat with a barbell and the constraint that we're going to put in place is that that barbell is going to have no weight on it. You are not terribly constrained. You are able to move in all sorts of ways and people can what we'll call self-organize, which means that they are able to, with repeated practice, end up essentially identifying a pattern of movement that is comfortable, is tolerable. Of course, a lot sometimes people might need a little bit of coaching if they're more on the beginner side.

1:12:16But over time, people do tend to self organize and identify things that you'll hear from describe as working better for them. Or if they've often experimented with different styles of movement, they have kind of self identified some of these things. Now, if we change the task constraint, to say that instead of no weight on the bar, we're going to put 500 pounds on the bar, suddenly, there are many fewer options in terms of ways that the person can successfully move that weight. So the constraints put in place, or alternatively, if I change the environment, maybe I put them on a different planet with a very different gravitational pull or something like that, then that would also change what are the movement options available to the person.

1:12:53And so that is the concept where these different aspects can interact to lead to the kind of what we'll call emergent aspect, what emerges in terms of the way the person moves, and how they tolerate it, and how they adapt to it, and how they kind of organize over time. I know you've looked at some data on high level athletes and how they move and found some surprising findings. You want to summarize those? Yeah, yeah. I mean, even elite athletes, when they actually measure them using like pretty high tech, like motion capture software, they move differently. Each time they do a rep, it can be 75 % of the one rep max on a back squat, it could be 90 % of their one rep max on a back squat or deadlift, there's significant variability from rep to rep in all three planes, right, in three dimensions.

1:13:37And it's like, well, look, you would expect elite lifters. These were international level lifters that they would be able to do it like a robot. Everything's the same, every single rep, but it's not. And certainly they're trying to do so, right? This is a very like, this is kind of a social construct. Like people want to do this because they believe it to be better, more efficient, but that's not really the case. And so I think the takeaway here is that variability isn't an error. It's just a strategy. Body is a complex system of millions of parts. It self-organizes differently every rep to solve the problem.

1:14:11That's to lift the weight. If you try to force a lifter to move sort of invariably, like a robot, it might increase injury risk because you're preventing the tissues from sharing the load, to moving into a more powerful or stronger position, something that's more ready to do the task with the constraints that are being given. So we're not like robots. We're more like biological jazz musicians. We improvise slightly every rep, and that's a feature, not a bug. All right, one last thing before we move on. Look, if safe lifting technique, bend at the knees, keep your back straight, actually worked, we would expect warehouse workers who get trained in this or nurses, for example, who get trained in this to have fewer back injuries, right?

1:14:50Apparently not. We have huge data sets on this where employers spend millions of dollars teaching workers how to lift properly. But the result is that there's nearly zero evidence that this training prevents back pain, disability, days missed at work. We've tried to, quote, technique our way out of back pain or back injuries in the workplace for 40 years or more in the workplace, and it's basically failed completely. Why? Well, back pain and pain in general is complex. It's not just lifting correctly. It's not a geometry problem. It's just more nuanced than that. so if the definition for quote perfect form is circular and we don't and we shouldn't move like robots uh and workplace safety training doesn't really work what the hell are we supposed to do austin i think that we've been hammering the key message throughout this uh episode so far and i think it's probably time to start to as the as people i i hear saying more and more often on podcasts these days we need to land the plane and start to bring this together into a useful kind of practical model.

1:15:47And it comes down to differentiating and to some degree, like de-stigmatizing the concept of bad form or bad technique as people commonly identify it, and kind of reframing that as more of an inefficiency in movement that can potentially be, you know, rectified, improved, whether by coaching or by continued practice and this concept of self-organization. We've also reframed the idea of like, well, what is the actual risk at play of moving in this way. And of course, there are a lot of variables that inform that risk. How prepared are you for doing the thing you're trying to do? How much in excess of your current capacity is this thing that you're trying to do in this way?

1:16:23And that is, again, where we're gonna continue to bring our attention back. I would love to see people trying to move in all sorts of different ways and experimenting, particularly early on in their athletic training, lifting journey, exploring all the different ways that their body can move, slow, fast, unilateral, bilateral. explosive, slow, things like that, and end up doing this long-term self-organization process. Eventually, the beauty of it is as you do this, and as you get feedback, both like what we'll call interoceptive feedback, you're at what you feel inside, or if you get coaching and external feedback, and we can kind of gradually organize this over time, you end up developing the preferred ways that you can move best, and you can build that capacity, and you can achieve great things by doing that.

1:17:09And you can do it without needing to think so hard about every single rep. This is why if you put a bar on your back or my back or in our hands and ask us to squat it or bench it, or if you still now a decade later, throw me in a pool and ask me to swim a lap, I can do it with quite good technique. And it does not require a whole lot of active thinking or cuing or worrying about details because of the sheer amount of practice and exposure and self-organization that we've had kind of along the way, including I'm sure lots of reps that did not look quote quote unquote, pretty or optimal per current kind of social, you know, concepts of those things?

1:17:40Yeah. Well, I think we've sufficiently burned the house of technique down. So we got to build something in its place. And we need something that's more like a compass and not a rule book. And so the model that we've been using for exercise technique is called the REP model. There's an acronym, it stands for repeatable, efficient, and that the exercise or the style that you're using, it meets the points of performance. So repeatable means that the individual should perform the exercise in a way where the range of motion, the joint angles, the movement velocity, the tempo, and the overall movement pattern is, they're somewhat similar rep to rep.

1:18:16Now, of course, individuals move differently from one another, and when the analysis is constrained to a single person from rep to rep, thus we're gonna accept some rep to rep variability, though the range of motion, the joint angles, the velocity, and the tempo should remain fairly similar. That means that your squats should mostly look like squats throughout the set and not squat, squat, squat, good morning, for example. The movement should also be efficient in that it should maximize performance for a given level of energy and effort. In other words, an individual should aim for a technique that minimizes muscular force production that does not contribute to completion of the task.

1:18:49So in a deadlift, for example, if the bar starts way out in front of you and you have to expend all this energy to roll it back, get it into position, and then lift it, that's not very efficient. You can see this when people's hips move up or down prior to the bar leaving the floor, for example. And then finally, the P of the rep model, that the movement style meets the points of performance. So these are like pre-specified constraints like are we going to squat below parallel? Are we going to pause at the bottom? Are we going to use a specific tempo? Is it going to be very fast? Ultimately, these are pre-specified to meet the goals of an exercise.

1:19:25So what do you want to get out of it? A lot of these things are arbitrary, but still, that's the end of the REP model. And Austin, you'll note that this model intentionally avoids advocating for specific anatomical relationships, like the knees have to stay behind the toes. You've got to maintain a, quote, neutral spine. Why do you think that I left that out if you had to guess? Yeah, I think that because those are not pertinent variables at play here. I think that we allow the constraints of the task to inform those anatomic relationships rather than prescribing the anatomic relationships ahead of time.

1:20:03So, for example, if you said that anytime you lift a weight from the floor, you need to maintain a neutral spine. Well, suddenly you have to forfeit the Atlas Stone lift when you go to your strongman competition. It is literally not possible to do that movement with a neutral spine. Completely not possible. That is inherent to that task because of the constraints of lifting a heavy ball off the ground, for example. We also know that if you perform a deadlift or if you perform a squat, even when visually it looks like your back is flat, when this is actually measured using more advanced biomechanical measurement techniques, that people's spines are in fact flexing.

1:20:36It is unavoidable to some extent. So trying to prescribe these anatomic relationships ahead of time is not only unhelpful, but many times makes certain tasks impossible. Rather, we apply this model and the task constraints and then allow the person to explore kind of what we'll call the movement space, the options that they have available to them. And in particular, when it's a situation where we're introducing it, it generally is going to start out with lower loading, where they have more of those options. And then as we progressively load it over time, then yes, the available movement space, the number of options they have available to them will narrow the heavier it gets to improve that efficiency once they've had sufficient exposure and practice and adaptation to that task or preparation for what they're trying to do.

1:21:23So the task constraints are what inform this kind of self-organization more than us organizing the lifter into the positions that we want them to be in. Yeah. And oh, by the way, those positions are going to change over time. Individuals get stronger, their individual strengths and weaknesses and movement preferences and understanding of the constraints, all that stuff changes almost like in perpetuity, as long as you keep going. So these things are going to change, and so does technique. But ultimately, if it's repeatable, if it's relatively efficient, and it meets the arbitrary, pre-specified points of performance based on your goals, you're probably good.

1:21:56You don't need to worry about technique anymore. So where do we leave this? We started this episode with the image of an influencer drawing red lines on a squat and screaming Snap City. They sell you on the idea that you're a fragile machine, a car with a bad alignment, a ticking time bomb waiting to explode. But today, we looked at the evidence and we found out that narrative is a lie. We learned that pain does not equal tissue damage and that most injuries in the gym aren't catastrophic. We learned that your spine is not like a brake pad that wears out. It's the living system that adapts, builds a callus when you load it.

1:22:28And we learned that the usual suspects, such as heavy weight, moving at a fast velocity and age, well, they're mostly innocent. Now, the industry wants you to believe that the biggest risk in the gym is rounding your back when you deadlift. But the data proves that the biggest risk is actually the nocebo effect, letting someone convince you that you are broken. The second biggest risk is load management, trying to spend a budget that you haven't earned yet. And the third is hyper-specialization, never rotating the tires and letting a hotspot develop. So here are your marching orders. It's time to stop playing defense and start playing offense.

1:23:00Number one, stop optimizing for quote safety by avoiding specific exercises. You're safer in the squat rack than you are on the soccer field and using a wide range of exercises is like an expansion pack for your physical abilities. Number two, stop trying to move like a robot. Use the rep model. If it's repeatable, efficient, and meets the points of performance for the exercise, your technique is probably good enough. Instead of focusing on technique, focus on executing your reps with maximum intent. And number three, manage the dose. Avoid doing too much too soon. Most of your work should not be maximal, particularly on compound exercises.

1:23:34While it's not risky to lift heavy per se, going too close to failure too often can be tough to recover from. Most of your work should be done in the RPE 6-8 range. Build the callus, not the blister. Now we know that this is a massive mindset shift. It is scary to ignore the red lines. And to help you navigate this, we have created the Barbell Medicine Injury Risk Action Plan. It's free, it's in the show notes below, and it's waiting for you right now. Download it, immunize yourself against the BS, and let's get strong. We'll see you next week.

1:24:09We'll be right back.