JOSEPH D. FORTIN. DO FRANK J.E. THE BIOMECHANICAL PRINCIPLES OF PREVENTING WEIGHTLIFTING INJURIES From Spine Technology and Rehabilitation Fort Wayne, Indiana (JDF) and Department of Physical Medicine and Rehabilitation “Temple University Medical School Philadelphia, Pennsylvania (FUEF) Reprint requests to: Joseph D. Fortin, DO President Spine Technology and Rehabilitation 7280 Engle Road Suite 210 Fort Wayne, IN 46804 Weightlifting has grown in popularity over the past 30 years as an important raining element for a variety of sports and as an individual ath— etic event, There are currently about 10,000 aotive powerlifting competitors and over 20,000 bodybuilders in the United States. The advent of the cross training concept (i.e., weight training to boost performance) has secured a role for weightlifting in most athletic endeavors. Each Year about 1.5 million youth play football. In preparation for this sport, the majority will be in- Polved in some type of weight training program. “As weight training becomes an integral part of athletic conditioning, it is essential that the physician who treats these athletes understand the pure of the training program. ‘The physician must be able to determine if the injury is related to the weight training program and if the program can be altered to prevent injury. Understanding the biomechanics of injury enables the physician to provide treatment based on scientific princi- ples and not on myth or tradition. “There needs to be a better appreciation of strength training and its relationship to the occur- Fence of sports injuries. There is evidence sug- gesting a connection between Tumbar spine injuries and weightlifting. Brady etal. reported 2 asal relationship between the development of fumbosacral pain and weight training in 29 indi- viduals Seven of the 29 required hospitalization With two undergoing lumbar discectomy and an- other two receiving lumbar fusion for spondy- Tolisthesis. Thirty percent of college football PHYSICAL MEDICINE AND REHABILITATION: State of the Art Reviews— SOL II, No. 3, October 1997. Philadelphia, Hanley & Belfus, Inc, 697698 FORTIN, FALCO players have missed playing time due to lumbar spine complaints and there has been a greater than 10% incidence of spine injuries in the National Football League (NFL) necessitating time lost from play." The reported incidence of pars defects has been higher in weightlifters than in football players or the general popula- tion.!8224 There may be a higher incidence of degenerative lumbar spine changes in weightlifters than in track and field athletes who lift weights as a part of their train- ig regime to improve performance.! No other sport imposes such tremendous loads on the spine as weightlifting. 6 Although some weightlifting feats exceed loads greater than 20-30 KN, a normal lumbar motion segment may fail at compressive loads not higher than 10-12 KN.” Hence, itis likely that some complaints of spine pain attributed to a given sport may be secondary to the strength training conditions versus the athletic endeavor itself. Several studies indicate that the nature of weightlifting injuries relates to the weight training rontine. In Olympic weightlifting activities, the wrist, shoulder, and knee regions are injured more than the low back. This results from forcefully “rotat- ing out” from the weight and rapidly accelerating into the low squatting position. In contrast, the low back is probably the most common site of injury in the weight training and powerlifting population.”? Brown and Kimball reported that 50% of all juries in adolescent powerlifters were to the low back.? Although the kinematics and kinetics of skilled versus unskilled weightlifting performance have been investigated in many studies, few attempts have been made to relate these differences to the patterns of injury. The lack of rigid scientific valida- tion of strength conditioning methodology does not obviate the need to apply sound biomechanical principles to prevent weightlifting injuries. In this chapter we will explore the prospect of spine injury in skilled versus unskilled weightlifting execu- tions, A kinesiologic perspective will be developed and adapted to address common rehabilitation issues. WEIGHTLIFTING Olympic weightlifting involves lifting the maximum amount of weight using the snatch, and the clean and jerk techniques. The snatch involves pulling the weight from the floor, catching it overhead in a squatting position, and then driving it upward to a standing position. The clean and jerk is a two-movement maneuver. The athlete pulls the weight from the floor in the clean and catches it at shoulder height in a squatting position before assuming an erect position. The jerk consists of accel- erating the weight from the shoulders to an overhead position. ‘The goal of powerlifting is for an individual to lift the maximum weight possi- ble in the squat, the bench press, and the deadlift. The squat consists of holding the weighted bar behind the neck on the shoulders in the standing position, squatting to a position where the thighs are parallel to the floor, and then returning to a standing position. The bench press involves lowering a weight to arm’s length. The deadlift will be explained in detail later. Bodybuilders develop muscular hypertrophy, definition and symmetry through weight training. Strength is not the primary objective of bodybuilders, although powerlifting is used as part of their training. Many athletes use a weight program to supplement and enhance their perfor- mance. It most often involves repetitive action against submaximum resistance. Weight trainers who seek explosive power and muscle hypertrophy typically employ powerlifting and weightlifting maneuvers in addition to their other weight training techniques.> WEIGHTLIFTING INJURIES 699 CS ——r—C—C—CCE™—E greatest re~ cruitment of muscle mass for execution. They complement many spor's activities round include the deadlift, squat, snatch and clean lifts 217448! These exercises How the highest power output and the best overall strength gains.” Tnrermediate level movements (bench press, behind-neck press, bent-over-ront and leg press) incorporate fewer muscle groups and joints. These @xou" train gnough major muscle groups to benefit most athletes. Ancillary of assistance exer cae etauch as leg extensions, hamstring curls, calf raises, and arm or DicePSs curls and fice further isolate one of two muscle groups and joints, allowing the athlete to con- Centrate on sports-specific muscle groups (i.e. the calves of a dancer or forearms of atennis player). Spine Stabilization essential biomechanical objective in weightlifting is the transfefence of roads from the shoulders to the ground, The inextricable link of soft tissues from the hips to the shoulders allows this transfer of weight) Muscle fibers of the hip exten- ———"_—D the tendi- hous portion of the latissimus dorsi muscle that eventually inserts on the humerus 5-5! The tension on this “cable” of interwoven connections 1s regulated by arte mascle control and passive tensile ligamentous forees resulting from postural dynamics as the pelvic tilt. Maximizing the amount of weight lifted while minimizing the loads on the spine necessitates awareness of a basic postural stratagem.** Postural equipoise for the ase uereiaes entails: (1) staying as upright as possible throughout the ifs (2) main- taining the head carriage over the shoulders; (3) balancing the shoulders over the base Gf support; (4) using posterior rotation ofthe ilium (he, pelvic tilt) as the primary force to approximate the weighted bar to the long axis of the body, except in the Paableskenee-bend (see below); and (5) keeping the load balanced as close fo the center of gravity line as feasible throughout the lift in order to diminish lever arm distances. Surcoseful rehabilitative and preventive measures provide education about fun- damental concepts of strength conditioning and various lift techniques and the prin- ciples of elastic energy storage and stretch reflex facilitation. The muscles of the cee and extremities are balanced to length and strength, and dynamic post al con- ee —————L stabilization exercises.* The Deadlift BIOMECHANICAL ForCE ANALYSIS Figure | depicts a weightlifter who leans forward to Tift a weighted bar from the floer in front of him. Tensile forces applied to the upper extremity together with hr ——r——————— the planes of the lumbar dises.!°* These anterior forces are opposed by posterior re- = =——— extensors. ‘Attempts to assume an upright posture are aided by extension at the knee and ankle. ‘The majority of the muscle power for maintaining the trunk in af upright posture is afforded by the hips and thighs. Regardless of the degree of hip flexion some exten- sion power is supplied by the gluteal muscles, which are capable of generating a sino of 15,000 in/lb.2*® The spine extensors are often incapable of generating a posterior shear force adequate to oppose the anterior shear elicited by the body and700 FORTIN, FALCO Head Neck Shoulders © Baylor College of Medicine 1987 FIGURE 1. Operative forces which affect spine loads in the deadlift. A, the superincumbent weight generates large anterior shear forces across the lumbosacral motion segment. These forces are opposed by the concentric contractions of the hip and spine extensors (curvilinear arrow). The IAP (intraabdominal pressure) mechanism diminishes the effects of the superineumbent loads (open arrows). B, the above forces are concentrated at the neural arch. barbell weight because of their location close to the axis of rotation. The interactions of these forces are concentrated at the neural arch.*™'® SEQUENTIAL ANALYSIS A study of the deadlift allows insight into the biomechanics of all weightlifting maneuvers. The deadlift involves lifting a barbell from the floor to an erect position in one continuous motion (Fig. 2). The deadlift can be broken down sequentially into the starting position, lift-off, knee passing, and completion. FIGURE2, The deadlift motion. A, starting position. B, lift-off. C, knee passing. D, lift completion.WEIGHTLIFTING INIURIES 701 FIGURE 3. Superb deadlift technique in a world class powerlifter. A, lift-off. B, knee passing. C, approching lock-out (the final position). D, lift completion (photo sequence provided courtesy of Mike Lambert, editor Powerlifting, USA). ‘The lifter positions himself so that the center of gravity is over the base of sup- port in the starting position (Fig. 3A). He assumes a flat or slightly flexed back posi- tion, and holds that position throughout the lift to reduce motion and shear across the planes of the discs while still maintaining optimal tension on the posterior jumbar ligaments. The attitude of the trunk to the vertical is not greater than 45° which allows the hips and knees optimal leverage. The athlete in Figure 4 demon- strates a poor starting position with a rounded back and a trunk attitude significantly less erect (Fig. 4A). Being less upright, his hips are more flexed and not as advanta- geously placed for optimal torque. ‘Atlift-off the athlete assumes a relatively upright posture (Fig. 3A) and stabilizes his spine in a consistent alignment to reduce the overall spinal excursion and torque. The hip extensors are effectively employed in posteriorly accelerating the torso, as the long axis of the body moves closer to the barbell (Fig. 3B). Upon correct lift initiation02 FORTIN, FALCO FIGURE 4, Poor deadlift technique in a world class powerlifter. A, lift-off. B, knee pas C, approaching lock-out (the final position). D, lift completion (photo sequence provi courtesy of Mike Lambert, editor Powerlifting, USA). the gluteal muscles generate maximum power obviating the need to rely on the weaker erector spinae muscles. Sufficient tension is maintained on the posterior lumbar liga- mentous system throughout the movement until the moment is small enough for the back muscles to balance it." Poor technique at lift-off (Fig. 4A) necessitates that the lumbar spine undergo a greater excursion to complete the lift while sustaining a large flexion bending moment. The application of inordinate forces may cause disc nuclear contents to be forced through the end-plates or posterolateral corners of the an: nulus (which act like stress risers). If the lifter pulls the weight unevenly or loses control, turning to one side or the other, torsional stress across the intervertebral joints intensified. If the posterior arch is forced beyond two or three degrees of deforma- tion, concomitant damage to the facet and annulus may occur.*°8! ‘The largest moment is attained as the weight clears the knees, farthest from the Tumbosacral axis of rotation. The weightlifter is simultaneously extending his hipsWEIGHTLIFTING INIURIES 703 and knees in approximating the weighted bar to the long axis of his body. Otherwise he would incorrectly overutilize the spinal extensor muscles, thus increasing the stress on the intervertebral joints, The athlete continues extending his hips and knees while retracting his scapula in completing the movement to assume an upright posi- tion, Figure 4B illustrates the athlete leaning backward early in the lift sequence be- cause he is extending his knees without simultaneous hip extension. Intradiscal pressure increases when lifting the knees extended versus flexed. ‘There should be no hyperextension upon completion of the lift (Fig. 3C, 3D). The athlete using poor technique throughout the lift often will compensate at com- pletion by hyperextending through the lumbosacral axis (Fig. 4C, 4D), placing sub- stantial stress to the erector muscles and overloading the facet joints. Predominant erector spinae activity is also detrimental because it interferes with the transmission of hip extensor forces by the lumbosacral fascia which must stay taut with a flexed lumbar spine.2” Extension of the spine causes the tip of the inferior articular process to impact the subjacent lamina. The upper vertebra undergoes axial rotation if the load continues to be applied to the extended joint." This situation may lead to capsular strain or rupture, erosion of the periosteum of the lamina or annular disruption."° The increased incidence of neural arch defects in athletes involved in sports requiring repeated forceful hyperextension has been well established, with a 30% incidence of spondylolysis in one series of weightlifters.21979967#895198 (CINEMATOGRAPHIC ANALYSIS OF THE DEADLIFT MOTION Itis generally accepted that prevention of athletic injury and rehabilitative mea- sures do not always correlate with the actual kinetics and kinematics of perfor- mance. The authors examined data from a previous motion analysis study of the deadlift226 Brown and Abani’s study of 10 skilled and 11 unskilled adolescent pow- erlifters used cinematographic analysis to develop a multisegmental model of the deadlift motion in the sagittal plane? Figure 5 represents a reconstruction of the deadlift motion of one of the skilled subjects. The horizontal moment arm of the ankle, knee, and hip are plotted versus time. The area under the diagonal lines represents the lift-off. The time at which the knee 2 (ae erst a2 UEisubject No. 88 7 “Subject Wt. (kg) 98.29 Bar Wt. (kg) 259.09 oi os, co FIGURE 5, Skilled lifter sagittal reconstruction of the deadlift. Horizontal moment arm of the hip, knee, and ankle versus time. (Adapted from Brown EW, Abani K: Kine- maties and Kinetics of the dead-lift in adolescent power- Ss lifters. Med Sci Sports Exere o- ie 72:554, 1985.) oe Hor, Moment Arm (M) Sy 0.08! 10.00 0,80 1.60 2.40 3.20 4.00 4.80 5.60 6.40 Time (see)704 FORTIN, FALCO 0.56 onal ae anne Po = os sp FIGURE 6. Unskilled lifter. A ood ee J Sagittal reconstruction of the <2 a re deadlift. Horizontal moment dl os arm of hip, knee, and ankle 5 oe versus time. (Adapted from g gs, Brown EW, Abani K: Kine- a ES, matics and kinetics of the 2 eubiect Na TeY dead-lift in adolescent power- 0.08) Subject Wt. (kg) 105.45 lifters. Med Sci Sports Exere Bar Wt. a) Mea 72:554, 1985.) 0.00 Se a -0.08! 0.00 0.80 1.60 2.40 3.20 4.00 4,80 5.60 6.40 Time (sec) weight “clears” the knees is indicated by a vertical line. A comparison of Figures 5 and 6 demonstrates that the skilled lifter starts with his trunk in a more upright posi- tion than the unskilled lifter, as evidenced by a smaller horizontal moment arm at lift-off. At knee passing, the horizontal moment arm of the hip rapidly approaches 0 in the skilled lifter as he effectively uses his hip extensors. In contrast to the unskilled cohort, all of the skilled subjects achieved a positive angular trunk acceleration commensurate with the moment the barbell cleared the knees. The hip extensors accelerate the trunk into extension utilizing posterior pelvic tilt, thus allowing the lifter fo assume an upright posture.® This early burst of hip ex- tensor recruitment while the erector spinae are relatively silent allows the weighted bar to gain velocity at knee passing.** An athlete who chooses a stooped posture at lift-off may be unable to coordinate this acceleration with knee passing. Accordingly, kinematic studies available to date demonstrate that skilled lifters attain a higher vertical bar velocity at sticking points. Figure 7 represents torque forces occurring at the hip, knee, and ankle in an un- skilled lifter performing a deadlift. Attempts to jerk the weight upward by repeated hip. truncal, head, and neck flexion followed by rigorous extension in a whiplash motion are represented by the erratic lines. Tremendous forces are necessary to rapidly accelerate and decelerate the barbell. Skilled deadlifters and squatters apply consistent vertical forces to the bar, thereby minimizing acceleration and inertial forces.°7” ‘The Squat McLaughlin and colleagues noted significant technique differences between skilled and unskilled powerlifters using cinematographic analysis.”* The unskilled lifters approached the low position at a faster bar velocity and therefore “bounced” or recoiled more. The inertial effects of “bouncing” cause increased shear forces across the lumbar discs. This presents as a potential axial overload situation and af- fords less control over the weight and a greater propensity for injury.* A slow con- trolled descent allows elastic energy to be stored that can be recuperated in assisting the concentric contractions of the hip and knee extensors on the ascent.”* The un- skilled lifters leaned farther forward in the ascent in comparison to the skilled ones.WEIGHTLIFTING INJURIES 705 05677 oa oo “Hp FIGURE 7. Unskilled lifter. © : ee Sagittal reconstruction of the 7 0.92 ee io “subject Wt. (kg) 74.20 deadlift. Torque versus time. Satan (Adapted from Brown EW, 2 024K eee Abani K: Kinematics and kinetics of the deed-litt in E osek adolescent powerlifters. Med Sci Sports Exerc 72:554, 0.08| ee 1985.) A {extension or Plantar Flexion Tig flenion or Dorallesion ate Pinion of 0.08 (0.00 0.80 1.60 2,40 3.20 4.00 4.80 5.60 6.40 Time (sec) Leaning forward increases the flexion bending moment and spinal compressive Toads. ? Leaning forward also disables the lifter’s proprioceptive control, which may ead to loss of weight control from one side or another. Forward flexion with rota- tion may increase disc pressure by 400%.* Athletes should be trained to descend slowly and drive the hips forward through extension while simultaneously extend- ing their knees without leaning forward in the early ascent (Fig. 8). FIGURE 8. The squat maneuver in a power rack (weight 470 Ib). 4, position of Tift initiation and completion. B, approaching the low squatting position Gust prior to the final dip"). C. early ascent phase. D, lateral view of early ascent phase. Note the torso inclination ig not excessive (approximately 40° to the vertical).706 FORTIN, FALCO Many lifters perform squats with their heels on a2 x 4 block, which places the lumbar spine in hyperlordosis. Some claim that this technique enhances quadriceps cruitment, but this extensor activity is merely offset by opposing flexor torque.” The shim is used also by some lifters to compensate for inflexible extensor groups at the hip, knee, or ankle. Proper form and muscle balancing prevent hyperlordosis and inordinate forward lean/flexion load. Nascent devices that place the weight closer to the lumbosacral axis of rotation may significantly diminish spinal compressive loads during squatting,” The effect of the squat exercise on knee stability continues to be a concern for physicians, coaches, and athletes, Previous criticisms of detrimental, destabilizing ligamentous disruption have been refuted by recent investigations.'*"4 Chandler and Stone (via the National Strength and Conditioning Association Research Commit- tee) have carefully illuminated the facts versus the myths associated with the squat exercise and have outlined guidelines for performance of the maneuver.'5 Olympic Style Weightlifting ‘A well-executed Olympic lift is an elusive display of optimal biomechanics, Lifting the barbell overhead after the second pull does not require balancing of large moments but rather tremendous neuromuscular coordination in controlling moments near zero. The double-knee-bend (DKB) is the style of weightlifting associated with comparatively less stress on the lumbar spine.?22* The double-knee-bend initially en- gages the hip extensors and subsequently the knee extensors through both joints strongest range of motion. This style involves reflexing the knees and rotating the torso closer to the vertical, after the barbell has cleared the knees (first pull). The rapid but controlled eccentric flexion of the knees enables the storage of viscoelastic kinetic energy and stretch reflex facilitation for the second pull The final, explo- sive knee extension (second pull) leads to the top-pull (full extension) position when the lifter begins to move under the bar to catch it overhead. Mechanical stress on the lumbar spine during the clean and jerk, as seen with other lifts, increases with load, speed of movement, and forward torso lean.*! Olympic lifts require blazing speed (5 and 6 m/sec? for clean and snatch, respectively) and the swift application (0.6-0.9 seconds) of great forces while loading many joints through a wide range of motion.*'-"49.0 Training must therefore enable the musculoskeletal system to endure rapid loading over the sports-specific spectrum of joint angles, Nautilus (or comparable variable resistance equipment) can be utilized to for- tify the eccentric strength of the hamstring and gluteal muscles, which are vital in determining torso inclination in the first pull.** Plyometric exercises provide a con- trolled medium for Olympic style lifters to develop fast-twitch strength and enhance the viscoelastic properties of connective tissue." Tilt boards, balance beams and dis- sociative (dance-like) exercises are excellent tools to build coordination and en- hance dynamic postural control. The stabilization concept trains the lifter to effectively use antagonists (i.e., gluteus/psoas or hamstring/quadriceps muscles) in order to reduce loads on the spine throughout all phases of a lift." WEIGHTLIFTING SYNDROMES AND INJURIES The Tired Neck Syndrome Some weight trainers perform an inordinate amount of exercises to the exclusion of other complementary movements. The resulting imbalance includes tight pectoralis minor and external rotary shoulder muscles as well as weak rhomboids, lower trapezius,WEIGHTLIFTING INJURIES 107 serratus anterior, and external rotary shoulder muscles. Examination reveals protracted scapula, poorly developed posterior deltoids, serratus anterior, and rhomboid muscles with relatively overdeveloped pectoral and anterior deltoid muscles. This inequity can lead to the tired neck syndrome, shoulder impingement, and hyperlordosis. At the end range of shoulder flexion in overhead lifts, compensatory hyperextension occurs through the lumbosacral spine as a result of the tight pectoralis minor muscles. A. graphic expression of a force couple imbalance about the shoulder girdle is a case report of a fractured first rib secondary to the overhead position of the jerk.” Adjunctive therapeutic exercises include wall slides, eccentric strengthening of the external rotary shoulder muscles, and rows. Eccentric strengthening of the shoul- der external rotary muscles and rhomboids is not addressed in most strength training programs, despite their role in indirectly determining the horizontal moment arm of the loads transferred from the shoulder to the torso. These muscles, by kinetically “checking” the anterior displacement of the glenohumeral axis (in the first pull of Olympic lifts and lift-off/knee passing of dead lifts), influence the cervicothoracic loads. Well-balanced shoulder girdle musculature will enhance a lifter’s longevity and symmetry. The Thoracolumbar Syndrome The thoracolumbar region is a vulnerable point of stress concentration as stiff- ness properties of the spine abruptly change in this region, and yet it receives little or no attention in conventional strength conditioning. °* Compressive and large flex- ion bending moments are enormous in the early phases of the deadlift and Olympic lifts as well as the early ascent phase of the squat when the superincumbent center of ‘mass and barbell is well anterior to the axis of rotation. Figure 9 shows a lumbar MRI of a powerlifter who presented with a thora- columbar syndrome. The etiology of her flexion injury became readily apparent upon a dynamic analysis of her lifting motions. Poor coaching did not lend itself to timely and explosive initiation of the pelvic tilt in the deadlift and early ascent phase of the squat. Thus, the lumbodorsal fascia and aforementioned posterior “cable” ‘were not taut enough to counterbalance the anterior thoracolumbar load. Sacroiliac Joint Dysfunction Superincumbent and ground reaction forces must ultimately be transferred from the load-bearing spine to the lower extremities by the sacroiliac joints, which serve as the final common pathway between the spine and the lower extremities. The keystone/interdigitating configuration of the sacrum and the pelvis together with balanced transiliac ligamentous and muscular tension allow a complex/dy- namic transfer of tremendous loads without sacrificing the ability to attain or main- tain an erect posture while locomoting or lifting. 5 1% Muscle balancing efforts, for patients with sacroiliac joint dysfunction, should concentrate on the powerful two-joint muscles around the sacroiliac joint (j.e., glu- teus maximus, biceps femoris, piriformis, and psoas) as they exert shear and torsion loads proportional to the strength of their contraction.*?8!04 The clinical presentation, diagnosis, and rehabilitation of patients with S1 joint dysfunction are detailed elsewhere." Extremity Injuries ‘The upper and lower extremities are at risk for injury during weightlifting activ- ities whether performing powerlifting, Olympic training, bodybuilding, or general708 FORTIN, FALCO FIGURE 9. MR images of a 31-year-old powerlifter with a thoracolumbar syndrome, A, T2 midline sagittal MR. Marked L1/L2 disc space collapse and desiccation are apparent combined with end-plate reactive changes and a small, contained disc prolapse (#1-L1 vertebral body, #2-L2 vertebral body). B, TI MR axial section (LI/L2). A right paracentral/posterolateral disc prolapse with spondylotic ridging is evident (shorter arrows). The large end-plate/Schmor!’s lesion (longer arrows) attest to the enormous compressive Toads this motion segment has sustained. ing of the extremities and proper lifting 26 weight training. Conditioning and strengths techniques can limit and prevent these types of injuries. Although muscle and/or tendon rupture are relatively uncommon with weightlifting, there are reports of this type of injury involving the pectoralis major, biceps brachii, triceps, quadriceps, hamstring, and gastrocnemius muscles. These injuries can be catastrophic for the athlete. Early diagnosis and prompt surgicalWEIGHTLIFTING INJURIES 709 consultation for tendon avulsion or mid-substance tears is important in order to opti- mize functional recovery. There is general consensus in the literature for early surgi- cal repair in the active athlete. Overuse injuries of the upper extremity such as medial and lateral epicondylitis also occur in weightlifters. This typically occurs when the lifter is not using correct technique or results from overtrained muscles not conditioned to lift heavier weights, Intersection syndrome has been associated with repetitive, high-resistance arm or wrist curls.!® The condition is characterized as pain and swelling along the radial volar portion of the wrist. The site of injury is where the abductor pollicis longus and extensor pollicis brevis cross over the extensor carpi radialis brevis and longus. ‘A transchondral fracture of the dome of the talus has been reported in a high school senior while performing power squats.’ The fracture occurred in the descent phase of the squat producing sharp ankle pain. The teenager was able to finish the squat repetition but could not continue the set due to pain. There was no swelling or bruising. He avoided further weightlifting activities and although he had difficulty with running activities, he was able to ambulate. He did not seek medical attention until three months later, at which time physical examination revealed only mild an- terior ankle tenderness and an inability to perform “toe-ups.” X-rays and bone scan of the lower extremity were consistent with a fracture of the medial aspect of the talar dome. In a series of 43 junior and senior high school athletes with weightlifting-re- lated injuries, four individuals suffered meniscal knee injuries.* Two of the athletes developed the injury while using machine weight equipment and the other two were injured while performing dead-weight lifts, All four students required surgical treat- ment of their meniscal injuries. The authors of this series raised the notion that young athletes may not have the strength to maintain strict technique through end joint range of motion when lifting, which can lead to muscle or joint injury. The use of machine weights does not appear to decrease the risk of meniscal injury com- pared to free weights. Cardiovascular Consequences Blood pressure is typically increased during weightlifting. Although the in- crease in blood pressure is brief, it can be very substantial. Recommendations have been made that an individual should not weight train with a blood pressure over 90 mmflg diastolic or 145 mmHg systolic. A complete medical evaluation and proper treatment are necessary before allowing a hypertensive individual to return to weightlifting activities. ‘Syncopal episodes also known as “weightlifter’s blackout” have been associ- ated with the squat lift.%* Dizziness or lightheadedness typically occurs with stand- ing after any squat movement as a result of blood pooling in the lower extremities. during the descent and a sudden decrease in cardiac output during the ascent. This is accentuated when performing the weightlifting squat by hyperventilation and the Valsalva maneuver, which exaggerate lower extremity blood pooling. Proper breathing techniques should be employed during the squat to help prevent a synco- pal episode. The lifter should never hold his or her breath and a spotter should always be present during the squat lift. If a weightlifter has a syncopal event, prompt medical attention should be sought to evaluate other potential causes of syncope.70 FORTIN, FALCO STRENGTH CONDITIONING Erector Spinae Muscles Spine extensors, as the multifidus, play an important role in assisting extension and opposing small flexion and possibly torsional loads at the completion of lifts. Unfortunately they are sometimes atrophic in weightlifters owing to muscle imbal- ance.5 These muscles must be assessed and strengthening exercises prescribed if weakness or underdevelopment is present. Balancing Lower Extremity and Pelvic Girdle Musculature In addition to back development, the lower extremity and pelvic girdle muscu- lature should be incorporated in the rehabilitation prescription for prevention of spine injuries to weightlifters. Tight hip flexors and quadriceps as well as weak ham- strings will limit the power and range of hip extension, and secondarily posterior trunk acceleration. Abdominal Development The erector spinae muscles are mechanically unable to balance loads exceed- ing approximately 20 kilograms.» Mathematical and clinical constructs indicate that the abdominal muscles provide a substantial “missing moment” required for heavy lifting. Further scientific validation is necessary to establish a resolute model which depicts the precise interactions between intraabdominal pressure (IAP), the posterior ligamentous system and spinal compressive loads throughout various phases of a given lift.4+#99.72#2.10 Nonetheless, abdominal muscles appear to be essential in counterbalancing large axial and torsion spinal loads. Their conditioning should be a basic element in any weightlifter’s preventive or rehabilitative program. ‘An electrophysiologic examination of the sit-up exercise underscores the value of stringent form in abdominal strengthening.” The initial 40-50° of trunk flexion is associated with the greatest abdominal activity involving the upper rectus and to a lessor degree the obliques. Oblique and lower rectus muscles are recruited with a weight held in the upper thorax region. Rotation of the trunk during the trunk curl will augment the oblique musculature activity. Paren- thetically, the significance of the oblique abdominal muscles and in particular the transversus abdominis in weightlifting should not be understated as they repre~ sent a much longer lever arm to oppose lumbar torsion loads than the short spine rotary muscles.555° The second phase of the sit-up relegates the abdominal muscles to an isometric role exclusively. Isometric abdominal activity in a position of optimal spine function in the early stages of spine rehabilitation can be used to avoid excessive compres- sive loads, but needs to be advanced prior to return to play. When performing abdominal strengthening exercises, the hips should be flexed and anterior pelvic tilt avoided for optimal abdominal isolation and prevention of lumbosacral hyperextension. A rapid succession of repetitions, with the head and trunk curled, physiologically obscures abdominal muscle isolation via central path- way irradiation or a mass flexion synergy effect.*S Patients with lumbar spine pain and especially those with discogenic etiology must maintain neutral spine alignment while performing abdominal exercises to minimize compression and torsion forces. Some patients with deconditioned abdominal muscles will need assistance initially to maintain proper spine alignment.WEIGHTLIFTING INsuRIES 71 REHABILITATION A four-phase treatment protocol for a powerlifter with a lumbar posterior joint dysfunction is presented below.** This protocol should provide a general framework that is congruent with the general principles described earlier. Phase I (week #1) A. Goal—Decrease inflammation and pain, B. Nonsteroidal anti-inflammatory medication. C. Local application of ice for 15-20 minutes three times daily to the lum- bosacral region. D. Deep cross-fiber massage following icing. E. Postural education emphasizing co-contraction of gluteal and abdominal muscles in maintaining optimal spine mechanics. Phase II (week #2) ‘A. Goal—Increase range of motion. B. Segmental mobilization of muscle energy techniques to improve lumbar motion segmental mechanics. C. Stretch hip flexors, quadriceps, iliotibial bands, and lumbar posterior lig- aments. Phase III (week #3): . Goal—Strengthening and conditioning. Abdominal strengthening (isometric-to-advanced rotary). Strengthening spine rotary and extensor muscles. Stabilization exercises including progressive plyometrics and the body cycle, E. Calisthenics: e.g., push-ups and squat-thrusts. EF. Plyometrics. Phase IV (week #4): A. Goal—Progressive return to lifting focusing on biomechanical efficiency in the deadlift motion. . Place the center of gravity over the base of suppor Avoid a “stooped” round-back position in the ini the torso as upright as possible throughout the lift). Use the power of the hip extensors in the early phases of the lift com- bined with simultaneous knee extension. Avoid hyperextension in lift completion. Emphasize controlled fluidity of motion versus sudden starting and stop- ping. This protocol was individualized for a specific case. The timing and focus of therapy will be modified according to individual athletes and their conditions. vpap> ion of the lift (keep mm > OD How Much Resistance ‘Training with heavy loads may facilitate neuromuscular patterns unapparent with lighter ones." Therefore, excessive training at low resistance to the exclusion of high resistance may be detrimental to performance requiring large loads and may even be injurious. The number of repetitions and the amount of resistance should be tailored to achieve specificity of training—thus there is a continuum of athletes ben- efiting from low resistance/high repetitions up to high resistance/low repetition. Olympic style training (or subdivisions therein as high pulls and push jerks) might read as follows: “runners” (halfbacks, receivers, and sprinters), “jumpers” (volley- ball, high jump, basketball, and hurdlers), “throwers” (shot-put, javelin, and712 FORTIN, FALCO hammer), “pushers” (linemen, fullbacks, sumo wrestlers), and weightlifters. Preliminary data on symptomatic and asymptomatic volunteers demonstrate that as maximal deadlift loads are exceeded, posterior angular trunk velocity curtails.* This finding is commensurate with the stress-strain properties of collagen and may pro- vide a reasonable index of a safe load for some lifts. When optimal form is compro- mised in any lifting situation, the magnitude of the weight and fatigue should be considered to prevent injury. To decrease injury potential, while simultaneously peaking power production and varying training stimuli, Gerhammer has suggested emphasizing lifts in the 70-90% range of one repetition max, since current data are insufficient to determine the exact resistance for any athletic goal.” The physiologic concept of periodization or eyclic training is also paramount in determining frequency, duration, variation, and specificity of any weightlifting program2*85 Machines Versus Free Weights The controversy surrounding the superiority of isokinetic or variable resistance weight training over free weights is frivolous. Manufacturer claims that (1) isoki- netic equipment (such as Cybex) allows muscles to shorten at a constant velocity at all speed settings, and (2) variable resistance equipment cams (e.g., Nautilus) match the resistance to the users maximal force-production capability curve have been re~ futed.54473855799 The challenge in strength conditioning is to tailor the benefits of the various methodologies to the needs of each athlete. Dynamic weight training is un- paralleled in enhancing neuromuscular coordination and explosive power 7258 °N01) Warnings of a high injury potential associated with rapid overloading exercises are ill-founded since the viscoelastic properties of bone and connective tissues allow them to absorb greater energy when subject to rapid loading. Moreover, properly executed free weight exercises can accommodate any muscle tension and the con- comitant lifting force by accelerating at variable rates in unconstrained patterns. Isokinetic equipment may allow torque and power measurements at appendicu- Jar joints but the reliability of spine data is uncertain. These machines have a viable application in charting strength gains, measuring effort consistency, and providing feedback for explosive contractions at high-speed movements. Variable resistance equipment advantages include: (1) joint and muscle group isolation; (2) reduction of injury potential through a controlled/constrained system; and (3) ease of resistance adjustment. Equipment Weightlifting belts afford an increase in intraabdominal pressure, which most likely varies with belt size. When positioned immediately above the greater trochanters, some belts may act by hamessing sacroiliac motion.'¥!% They may also aid the athlete by providing proprioceptive awareness of the attitude of the trunk to the horizontal in maintaining the optimal position of the spine for a given lift. Power racks can be used to prevent injury in some lifting situations, such as squatting at submaximal loads, but should not take the place of experienced spotters ‘at maximal or burn-out (submaximal repetitions to failure) efforts (Fig. 8). ‘As documented by force-plate analysis, the position of the foot indirectly deter- mines the relationship of the barbell to the lifter and torso inclination.\10" Weightlifting shoes are therefore an important consideration in preventing spine injury. Weightlifting shoes have a strong counter and medial and longitudinal arch gupports as well as a heel that affords mediolateral stability.WEIGHTLIFTING INJURIES 13 DISCUSSION Many injuries to the low back resulting from weightlifting or weight training are chronic ones with an insidious onset. The athlete, who is often engaged in other sporting activities, may be unable to precisely identify the time of onset. The adolescent athlete who presents with well-localized unilateral aching low back pain exacerbated by repetitive hyperextension lifting maneuvers may have under- fying neural arch defects. Early detection, and proper joint protection and immobi- lization, of a young athlete with spondylolysis, may prevent slippage (i.c., spondylolisthesis) and allow dramatic pain relief as well as return to activity within several months. It is essential to distinguish the athletes with the aforemen- tioned problems from the far more common ones with an uncertain diagnosis who have chronic low back pain, normal conventional imaging and diagnostic studies, no signs of nerve root irritation, and are relatively pain-free when not training. Such athletes may have the beginnings of posterior element changes and altered discovertebral or sacroiliac joint mechanics. Pathologically, these changes may consist of facet or sacroiliac joint synovitis, focal cartilage necrosis or fibrillation, cnd small circumferential tears of the annulus (unimpressive on routine stud- jes)22298.05 This differential diagnosis can be formulated by the employment of provocative injection techniques.!?9#:9407 Unless predisposing structural imbal- ence and technique factors are considered as part of the overall rehabilitation equition, athletes may incur further damage or continue to have chronic pain. ‘Although the majority of the more common spinal afflictions secondary to ‘weightlifting are amenable to a conservative approach, problems that require sur- gical intervention such as cauda equina syndrome or those that may contraindicate Some type of therapy such as spinal instability must be identified. The aim of treat ment is to decrease pain to a tolerable level and increase spinal range of motion, stability and strength to functional levels. 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