Rehab.
The place of the magic healing wands that do not even need to plugged in to “work”.
The place where you can get a hot pack and an average massage for just a $30 co-pay.
The place where the squat rack is only used to hang equipment off of and ultimately-
The place where strong people go to die.
This is the unfortunate truth in most instances. However, this does not mean that everything that comes out of the clinical and rehabilitation realm is useless. In fact, in a perfect synergy of professional cooperation with the a client-centered approach, rehabilitation and training should look exactly the same minus one small difference.
Rehab is just training with a current injury.
Not only is it that simple but some of the exercises used in a clinical setting have application to training scenarios and fitness goals as well. Clinicians are commonly called out in the fitness industry for use of a barrage of non-functional and non-challenging exercises. Too often this results in people living a life of pain and physical limitation because “rehab did not work for me”. However, with an understanding of correct application, there are specific “rehab” exercises that can not only help your clients feel better but connect well with their current programming to push them towards their physical goals.
Where does the clinical world go wrong?
First off, a little context on rehab exercises.
A high percentage of the movements chosen in a rehabilitation realm are based off of Electromyography (EMG) studies. EMG is a technique used in medicine to measure and record the electrical activity produced by skeletal muscle. The higher the EMG, the more that muscle is producing an electrical signal (firing).
Now, for most graduate level programs, exercise selection is taught based on EMG studies. If you want to get someone’s ass stronger, you need to choose the exercises that have a higher EMG for the ass.
Sounds simple, right.
The funny part is, the higher EMG signals for specific muscle groups are typically found in non-functional (i.e., non- weight-bearing) positions. Again, this kind of makes sense. If I am standing and squatting, I am going to use the entire chain of muscle from my ankle to my mid and upper back to move that weight because all of those structures are upright, moving against gravity and inherently involved. If I am in a more isolated position (such as in a side lying leg raise for the glute med) there are not really too many muscles that are going to perform that action except for the one I am trying to target (in this instance, the glute med).
Side note– we are not going to even spend time talking about surface vs intramuscular EMG because frankly, it does not matter. Just know that surface EMG tends to have a higher % of error due to it not actually being inserted into the muscle tissue.
Now here is the crazy part.
I spent more time in a Doctoral level education program having to read EMG studies around isolated muscle groups than learning how to teach someone to squat or deadlift. Literally, we had ONE weekend around the big lifts. You read that right, ONE. Oh, and it was an elective.
Without a strong background in athletics and strength and conditioning, I would not have known a good squat vs. the one used after eating too much cream of rice. Yet, what are the things that actually keep people getting stronger and feeling better a higher percentage of the time? Oh yeah, the hard “functional” shit.
Where people go wrong is in using only table based exercises due to high EMG but forgetting that as soon as someone stands up, all muscles, joints and proprioceptors are in play. This is the same reason that functional carryover does not happen from table-based programs.
The brain isn’t fucking loaded on the table.
Typical rehabilitation misses the mark by using table based exercises as the primary method to improve strength, function, pain, etc. Instead, what we should be doing is using some of these movements as supplementary exercises to the KPI (key performance indicator) or the biggest/hardest/fastest movement of the day.
If someone wants to be able to squat without pain, we need to be working on squatting. However, we can also be using isolated muscles of the squat (quads, hamstrings, glute, adductors, etc) as primer movements in a warm up, supplemental finishers or post-KPI accessory movements in order to bring up lagging muscle areas to make the squat stronger and less painful.
Now that we have a context of where we tend to go wrong, let’s get a plan of how we can go right with the inclusion of rehab based exercises.
Posterior-Lateral Hip
I have never in my career heard someone complain about doing too much glute work. In fact, I truly think that stronger glutes may very well be the fountain of youth. There is a mountain of evidence that shows that our chair-born and sedentary society doesn’t know what it feels like to feel their own ass. Call it what you want- sleepy cheek syndrome, gluteal amnesia, whatever. The point is, all of our inactivity and sitting causes a lack of vascularization to the glute muscles which in turn causes mitochondria to start to shrink due to the muscle loosing mass and size.
Atrophy is not cool.
Now, I am sure you have probably seen every “grow your glutes” program out there. Glutes are sexy and everyone wants a nice set of them. For the sake of time and poor attention spans, I am not going to present you with the next great glute program but will instead make some recommendations on my favorite lateral and posterior hip exercises (understanding, there are many) that are good options to combat the weak cheeks
1) Front Plank with Hip Extension
2) Side Plank with Abduction (down leg)
3) Side Plank with Abduction (up leg)
4) Single Leg Squat
The reason why I like these four the most is because they involve coordinated activity of multiple muscle groups as well as more “functional” aspects such as closed chain shoulder for planks or a planted foot in terms of the squat. They also have the highest EMG activity of the glute med and the glute max when combined (1).
How to Program
Lateral and posterior hip work is an excellent choice for those individuals who demonstrate functional weakness along the lateral and posterior chains. What this can look like is someone who has a hip drop when walking or when standing on one leg (Trendelenburg sign).
Glute primers and finishers are also an excellent idea for those people who spend a majority of their time sitting. So, basically everyone.
Finally, there is a bit of evidence suggesting that people who have patellofemoral pain syndrome (PFPS) can benefit from localized glute work as this tends to a weak area in this population.
The way you would program these would be either as primer in a 6-phase warm up (phase 4 for activation) as high muscle activity is good for an activation phase or as glute burnouts as the very last exercise performed that day.
I absolutely love table based or highly supported movements for an all-out burnout. The use of no to low loading through body-weight or bands makes it extremely hard for someone to get hurt and will allow them to feel the pump!
Essentially, localized glute work in the form of “pre-hab/rehab” movements could be programmed in one of the following three categories:
- Supplementary finishers
- Activation drills
- Off day training to increase weekly frequency
Copenhagen Planks
The Copenhagen plank is in my opinion, one of the hardest and most effective localized exercise for the often neglected adductors. While this exercise looks “simple” on paper, I have had multiple instances of Olympians begging to do anything to get out of them.
There is a tendency to think that all fixes to pain points starts with an emphasis on glutes and lateral hip strength. However, not only is this not accurate but I almost thing the pendulum has swung too far with rehab programs focusing only on posterolateral hip musculature.
To truly keep a body in balance, muscles should be strong on either side of the hip joint. When the adductors are untrained the results are chronic adductor and groin strains as well as diagnoses of sports hernias not only in the over 40 soccer league but also in the professional ranks with sports that require repetitive kicking/cutting.
The research would also support this point as it has been shown that people who suffer groin strains have weaker adductors (2-4). This is why every single professional soccer and rugby team in Europe use the Copenhagen plank regularly as part of an injury prevention strategy.
How to Program
Due to the isolated nature of this movement, it would be best programmed at the end of a session as a core/adductor finisher. The last thing you want to do is fatigue out someone’s core or adductors prior to a lifting session.
Superman
Just because you threw away your super hero pajamas from when you were younger does not mean you still cannot pretend to fly. In all seriousness though, one of the most neglected areas for strengthening is the low back.
This is a concept I still do not understand because there is muscle back there. Last I checked, muscle getting stronger was a good thing especially when it comes to improving low back pain.
Maybe it is the medical world preaching the dogmatic bullshit that direct low back training into an non-neutral position is worse for your health than downing a gallon of motor oil but that false narrative needs to stop.
Even though not all back pain can be treated with direct low back training, there is sufficient evidence to suggest that in non-specific LBP, low back musculature can atrophy (especially when the pain is chronic) and conversely, direct low back muscle strengthening has a positive impact on pain and function for some populations (4-7).
The other nice aspect of the superman exercise is that it coordinates not only low back musculature but basically the entire posterior chain which (as we know) is the largest opportunity area for just about every single person.
Increasing posterior chain ability will have a positive carryover to everything ranging from neck to shoulder to back pain. It is also a pattern that can be used for those who have pain with or do not have the equipment to perform a reverse-hyper/roman chair or other localized low back extension exercises.
Finally, we could coordinate cross-body slings by altering the pattern from all limbs at once to contralateral arm and leg combinations.
How to Program
The superman exercise is usually best performed as a finisher movement with a goal of holding for a set amount of time (like a plank) or for hitting a certain rep count. The nice thing about this pattern is that, due to un-loaded nature, it is safe to take to more of a failure rep range. It is important to also understand that because we will not add more load onto this pattern, the method that strength will improve is going to be more through metabolic stress than anything else.
Shoulder External Rotation
Whenever I think of shoulder external rotation exercise, I cringe.
I do this because it takes me back to my Doctoral level education where I spent hours upon hours memorizing every individual action, muscle, ligament and biomechanical aspect of the shoulder that is essentially useless in client application.
I literally spent six figures on a degree that resulted in me needing to forget more information than I had learned if I wanted to provide real-world results for my patients.
That is not cool.
Although there may be some benefit to side lying external rotation exercise, that 55 year old, former high school football player with chronically painful shoulders would most likely say otherwise because he has been doing them since 9th grade and his shoulders still hurt.
There has to be a better way.
When you look in a text book, you will see the rotator cuff described in a way that suggests that each muscle has its own individual action typically with the following pattern:
• Supraspinatus – initiates first 30 degrees of shoulder abduction
• Infraspinatus and Teres Minor – glenohumeral joint external rotation
• Subscapularis – glenohumeral joint internal rotation
Now, none of these actions is inherently wrong. These muscle do perform these actions when we looked at them in an isolated fashion.
The issue is that when we treat them as individual muscles and look through a lens of the rotator cuff as being a primary functional mover rather than appreciating its role as a primary functional stabilizer.
The rotator cuff does not predominately act as a rotator of the GHJ but instead acts as a unit of four to provide dynamic isometric contractions that keeps the ball on the dolphins nose centered. This is where we see the big disconnect between shoulder rehab and shoulder performance.
In a clinical setting, the emphasis is too often on rotation of the arm in an isolated fashion when in fact, the focus should be on asking the rotator cuff to act isometrically to provide stability to the joint.
To take this one step further, we also need to respect the fact that the GHJ also requires movement and control from the scapula-thoracic joint (the shoulder blade), the sterno-clavicular joint (clavicle on manubrium) as well as extension of the thoracic spine if we want to achieve a shoulder overhead position.
Basically, there is a lot of shit that has to happen for optimal shoulder function and more times than not, we completely neglect these aspects of shoulder training.
Disclaimer: This is not saying to avoid rotation of the shoulder. Your shoulder was made to rotate. Rather, what I am saying is to incorporate rotational aspects with synergy of scapular musculature because that is how every single shoulder works functionally.
With this being said, the following exercises are excellent choices for respecting the functional stabilizer activity of the rotator cuff while also including appropriate scapula-humeral contributions.
Powell Raise
The Powell raise is one of my go-to movements because not only does it include rotational aspects of the shoulder complex but it also hammers the most neglected shoulder stabilizer, the posterior deltoid. The posterior delt is the primary shoulder stabilizer anytime the arm moves closer to the body or behind.
So, as much as I enjoy bench pressing for the sexy anterior deltoid, the posterior deltoid is MORE important is it helps stabilize the shoulder as the bar is pulled down and the arm moves into an extended position. Where do most people get hurt?
On the eccentric or at the transformational zone between eccentric and concentric. This is where functional stabilizers (such as the rotator cuff and posterior deltoid) become the most important.
When performed correctly, the Powell raise also includes utilization of obliques (when performed in a side plank) as well as serratus anterior which again, are important but commonly-neglected areas.
How to Program
Due to the localized aspect, the Powell raise would be best performed as an AMRAMP/burnout finisher for a upper body focused day. This is not a movement where we are going for a heavy loading scheme. 10-15lbs is pretty damn hard for even those individuals able to bench 300+ so err on the side of going lighter to ensure you are really getting the pump.
Arm Bar
Not to be confused with the also power David Barr, the Arm bar is arguably the best exercise for shoulder stability. This is because the loading angle is 90 degrees direct into the glenohumeral joint which is the most stable position of the shoulder due to force closure from the load itself.
Practically, this means you can get pretty heavy for people here when appropriate. The arm bar also takes advantage of the rotator cuffs functional stabilizer action because the GHJ is required to maintain a centrated position coupled with rotation of the arm.
How to Program
The arm bar can be programmed in three ways. The first is used in the 6-phase dynamic warm up for those individuals who require more shoulder stability.
This can either be localized shoulder weakness or the individual who has excessive joint motion due to global hypermobility or prior shoulder injury (usually dislocations and/or labral injuries).
Using a 1-2 min time frame in a corrective exercise block would be ideal as a programmed aspect of the warm up. The other way to perform could be in a non-fatiguing time frame (<10 seconds) as an activation exercise prior to a heavier push movement during a session.
Non-fatiguing is important because the goals is to feel the muscle without fatiguing the muscle. We do not want to pre-fatigue the rotator cuff and posterior deltoid prior to stepping into a heavy push movement.
Finally, the arm bar could be considered for a post heavy push accessory movement. Typically, going for time works better than reps here because this forces the individual to think about technique rather than forcing a certain rep range.
I,Y,T,A
If you want to start an argument among clinicians, ask them to identify scapular dyskinesia. Measuring scapular dyskinesia (defined as altered position or movement of the shoulder blade) is one the most confusing clinical tests that exists.
Here is the funny part, in medicine we have spent endless hours debating what a “normal” shoulder blade looks like when in fact there is NO SINGLE clinical test that can consistently identify what scapular dyskinesia even looks like.
To top it off, there is also no good test that tells you what muscles are weak and how to “correct” scapular dysfunction. Finally, shoulder pain and scapular dyskinesia are not even correlated with each other!
We know the shoulder blade is important, we have just not been able to quantify what that really looks like for the person standing in front of you. This is where I like the IYTA exercise.
It coordinates scapular motion with glenohumeral control and (at least from an EMG perspective) is a nice “catch-all” exercise for the peri-scapular musculature.
How to Program
Due to the elbow being straight in the IYTA, there is a larger lever arm which will limit overall loading capacity for this pattern. Basically, we are not going to be loading heavy here.
Typically, using the IYTA pattern as a posterior chain burnout as the last exercise on a heavier push day works the best.
It allows for increased blood flow into the mid and upper back, it requires a higher rep range for fatigue which also assist in hitting a 3:1 pull: push ratio and when performed correctly, will leave you not really wanting to raise your arms for the rest of the day.
Conclusion
Look, I get it. Rehab sucks. However, rehab exercise don’t have to. When understood and programmed correctly, rehab based exercise can support even the best designed strength program
