When a powerlifter becomes injured in any respect, they rarely need to stop training or exclusively use non-barbell exercises during rehab. In fact, they must incorporate barbell training as rehab to optimize the athlete recovery process.
However, it's all too common for physical therapists and other rehab clinicians to fill "sports rehabilitation" with passive modalities, open-chain isolation exercises, and other resistance band exercises lacking sport specificity.
Couple this with a doctor's recommendation to "not do the barbell lifts," and we have a recipe for a long athlete recovery process and return to powerlifting at pre-injury levels or more.
Here's the problem:
When a powerlifter is injured, stops training, does therex, and gets manual therapy treatments at physical therapy, they may feel better and return to barbell training. Yet it's all too common that their symptoms return very quickly.
Here's what happened:
The powerlifter or barbell trainee felt better because they weren't doing the barbell lift that influenced their pain or injury. But barbell training and powerlifting injuries are a combination of training load, form, and training fatigue that influence tissue response and experience of injuries.
Powerlifting injuries are very rarely related to muscle imbalances, scar tissue, or specific soft tissue or joint tears. These things can all exist without pain and are likely in most asymptomatic and uninjured individuals.
When training load, technique, and recovery factors are not addressed in the rehab process, their symptoms are likely to return upon return to sport.
We'll say it louder for the people in the back…
Powerlifting injuries return after traditional physical therapy and rehab approaches because their physical therapy did not address the underlying cause of their injury or include barbell training as rehab.
They returned to training (probably at too high of an intensity), followed the same program, used the same technique, and didn't address sleep, nutrition, stress, and recovery. Instead, they went right back to barbell training in the manner that led to their injury in the first place.
Why do doctors and rehab clinicians tell people to stop barbell training or stay away from the barbell lifts causing them pain?
Firstly, most medical doctors and rehab clinicians do not understand barbell training, don't resistance train themselves, and look at training as black or white. You're either lifting an all-out max effort all the time or not lifting at all. So they think when you ask the question, "can I lift?” that you're asking about lifting 405 pounds. They also do not understand that load is relative. Relative to the person and the gravity of the injury.
Secondly, our narrative around pain is that if we have pain, we shouldn't lift. We often believe that if we feel pain, it's indicative of tissue damage or damaging us further, and 95% of the time, this isn't the case. Check out our article on training with pain here.
Nobody likes pain; we wouldn't be talking about this if they did. When an injured powerlifter or barbell athlete seeks out a doctor or rehab clinician, their goal is to eliminate their pain. Therefore, they're often given instructions to stop doing the painful thing. That's the obvious solution, and most symptoms will resolve without intervention once you remove the aggravating stimulus. But the risk of symptom return is high.
Simply resolving pain is not the REAL goal of the injured powerlifter. Their REAL goal is to lift without pain and make long-term progress without their training being interrupted by pain.
From a pain narrative standpoint, to accomplish pain-free barbell training:
The painful barbell lifts should be incorporated into the rehab program.
Education on acceptable pain levels needs to happen to reduce their fear of movement and fear of pain.
When we tell someone "don't do the thing that hurts," they'll likely interpret that as "pain is bad, and if I feel pain, I'm making my injury worse." This is not a productive narrative for anyone to have during the athlete recovery process.
To effectively treat the injured powerlifter or barbell athlete, we must first understand their goals.
The injured powerlifter or barbell athlete wants to:
Understand their injury and pain
Reduce and then ameliorate their symptoms
Continue to train with as little interruption as possible
Develop the knowledge, understanding, and confidence to reduce the recurrence of their symptoms once they're back to training at total capacity
Understand their injury/pain:
A powerlifter isn't the "average" population, and they don't just want their pain to disappear. Instead, they want to know why they have pain, what's causing it, understand how to rehabilitate it effectively, and what they should do to reduce the recurrence of their symptoms. In addition, they'll want to know what their pain means and if they should be concerned about further injury risk if they experience pain while training.
Reduce symptoms:
The injured powerlifter's brain is wired differently than most of your other clients. Their back might hurt when sitting for too long or bending over to put their shoes on, but that's likely not their biggest concern.
What they're thinking is:
→ "If my back hurts now, what implications does this have for my training later today?"
→ "Am I going to be able to lift and follow my program, or will I need to make adjustments?"
→ "If I need to make adjustments, what implications does that have for my training next week or next month?"
→ "Can I still plan to do a competition in 6 months?"
The injured powerlifter is coming to you because their pain keeps them from doing something very specific, but it may not bother them if they feel it during their daily activities.
So you need to understand their mindset, goals, and concerns when planning rehab that will truly be effective.
Continue to train without pain vs. return to sport:
Powerlifters DO NOT want to stop training, nor should they have to.
✅They want to continue to train the unaffected lifts normally, and they also want to learn how to train the painful lifts without pain.
⚠️They don't want to lose the progress that they've made, and the longer they skip certain lifts, the more anxious they'll be about it.
✅They want to learn how to continue training while reducing their symptoms and working towards training at higher intensities without pain.
⚠️They don't want to feel or be told that they should never or may never lift at their previous capacity.
When working with injured athletes, the term "return to sport" is often used in the rehab and medical world. In the traditional sense, return to sport happens at the end of the rehab process and is the period of time when an athlete returns to pre-injury levels of training or returns to competition.
Particularly with powerlifting or barbell trainees, we see that physical therapy or rehab ends, and they're left to get back on the horse alone. There's no bridge, no gradual progression to higher levels, and no valuable preparation or education for returning to regular barbell training.
This is where we see traditional physical therapy and rehab models fail powerlifters and repeatedly run into the same injuries and symptoms.
The injured powerlifter SHOULD continue training throughout rehab, and barbell lifts SHOULD be a part of rehabilitation. Powerlifters should train the unaffected lifts normally and the painful lifts with modifications to intensity, volume, and technique (if necessary) as part of their barbell physical therapy. Their program, recovery, fatigue levels, training trends, and technique should all be assessed and considered to truly address the problem and reduce their injury risk in the future. You can also read our free guide about healthy barbell training here.
Develop the knowledge, understanding, and confidence to reduce the recurrence of their symptoms once they're back to training at full capacity:
✅The injured powerlifter wants to know they're in control of their performance and progress.
✅They want to understand their symptoms fully, why they're experiencing them, and how to reduce the recurrence in the future.
✅They want the tools and confidence to manage symptoms if they arise in the future without feeling fearful that they'll have to take a big step back or take time away from training.
Traditional Physical Therapy education doesn't prepare us to address the needs of the powerlifter. We wrote a whole article about that problem here.
We weren't taught about programming, barbell lifting techniques, continuing to train through a barbell training injury, or how to assess what factors led to their symptom onset. To successfully rehab injured powerlifters, we must be able to understand and assess training factors, write barbell training as rehab, and provide future training recommendations.
We are taught to include passive modalities like massage, Graston, e-stim, and ultrasound in our treatment plans, but these modalities don't cause long-term resolution of the problem, only short-term relief of painful symptoms. Here, we also wrote a whole article about the issues with passive physical therapy modalities.
We should have the injured powerlifter continue to train throughout the rehab process and minimize the use of passive treatments, except when necessary for short-term symptom reduction and building trust.
So how can you specialize in barbell physical therapy and rehabilitation for powerlifters and other barbell strength trainees to help change the Physical Therapy narrative for the injured powerlifter?
Be a clinician and a coach.
Combine your clinical skills with the knowledge and understanding of powerlifting programs, techniques, athlete recovery, fatigue management, and tracking training trends. This will enable you to rehab the injured powerlifter while keeping them healthy long-term.
To be an effective physical therapist for injured powerlifters, you need education beyond a doctoral education and engaging in the sport. Read more about this in our articles on becoming a PRS Coach and why you should be a barbell coach and a physical therapist.
Below we'll outline what's necessary to include in the assessment and treatment of a powerlifter.
💥If you're a clinician, use this to help guide you with your next injured lifter.
💥If you're a barbell trainee, use this guide to help decide if the rehab treatment you're receiving is optimal to help you recover and train at full capacity again.
Barbell Physical Therapy & Rehabilitation Considerations For Injured Powerlifters:
We must consider the big picture when a powerlifter experiences a barbell training injury. Unfortunately, it's all too common that rehab clinicians default to placing the blame on barbell techniques, a specific muscle that's weak or "not firing," or structural or muscular asymmetries.
1️⃣ Technique alone is not usually the main culprit. If the technique were the main issue, then we'd be dealing with injuries daily as it's impossible to lift perfectly every rep of every training session.
2️⃣ Structural and muscular asymmetries are present in everyone from the day we are born and are also not usually the main culprit. Therefore, we should not tell people that flat feet or asymmetric glute size are why they are now experiencing pain after years of training without symptoms.
3️⃣ Muscles always work. If they didn't, you wouldn't be able to perform typical daily tasks. Muscles only "don't fire" if there is physical disruption or damage to the nerves that innervate them. So we should tell people their glutes not firing are why they have acute low back pain that developed after years of training without symptoms.
4️⃣ As we age, the structures of our joints age as well. As a result, most people over 18 have degeneration and tears within their joints' structures and surrounding tendons. And most of the time, people carry on without any symptoms related to these tears.
→According to a 2020 study published in the Journal of the International Skeletal Society A Journal of Radiology, Pathology and Orthopedics, 97% of asymptomatic knees imaged presented with abnormalities like meniscal tears, cartilage damage, and edema on MRI.
→ According to a 2019 study published in SPINE, 77% of asymptomatic subjects between the ages of 18 and 22 presented with positive findings in the spine on MRI, including disc narrowing, disc desiccation, herniation, protrusion, and extrusion
→According to a 2016 study published in the Orthopedic Journal of Sports Medicine, 52-77% of asymptomatic people between the ages of 45 and 60 presented with a shoulder labrum tear on MRI.
Given that these things are present in normal, healthy, pain-free individuals, here's what we shouldn't do to explain pain:
❌Tell someone their pain is solely due to a herniated disc, torn labrum, meniscus tear, rotator cuff tear, or other structural deficits.
❌Tell someone their torn meniscus (or other structures) are solely due to their bad rep at the time the pain developed.
Given the understanding that internal soft tissue and joint structure damage exists without being symptomatic, here's what we should do:
1️⃣ First, ✅ Evaluate the program, technique, and athlete recovery along with any other activities or stressors outside of training that changed around the onset of their symptoms.
2️⃣ Second, ✅ Assess and address the big picture to identify the multiple factors that lead to the experience of pain.
3️⃣ Finally, ✅ Make practical recommendations to help reduce symptoms and their recurrence.
So, where should the specialized barbell physical therapy evaluation or rehab assessment begin?
It's essential to run through the standard components of a physical therapy assessment, including a complete history, postural and functional assessment, and special tests to assist in painting the big picture. So we're not knocking the traditional physical therapy evaluation. But we will tell you that manual muscle testing is a waste of time with a powerlifter.
Training injuries are usually a combination of total training load, recoverability, and technique, and never one in isolation. As such, these factors must be assessed in the barbell physical therapy or rehabilitation evaluation of an injured powerlifter or strength training.
Your history should include a full assessment of their program and recoverability. Below is a quick rundown of what this means, links to additional free resources we've written on all these components, and ten specific questions to include in your history taking.
Total Training Load is the combination of training volume and training intensity.
→ Training Volume:
The amount of volume the lifter is doing for a specific exercise matters, and we need to consider it. For example, are they doing just enough volume to increase the training stress and make progress, OR are they doing as much volume as they can handle and may or may not be recovering from it?
Most people feel like more is better, and if they want to get stronger, they need to constantly push the envelope with their training.
This isn't true; less is typically better, as long as there's enough training stress to cause the lifter to adapt and get stronger.
→ Training Intensity:
The relative intensity for the lifter compares how much weight they're lifting to how much they can lift (their 1RM) and how hard they perceive the load to feel in the moment (RPE). In addition, relative intensity considers how recovered and fatigued a lifter is and their abilities to perform at that time.
Whereas absolute intensity is just the weight on the bar and doesn't tell us anything about how heavy the weight is for that particular person at that particular time.
So even though you might think a 100lb bench isn't very heavy, if the lifter's 1RM is 105lbs, then that 100lb bench is pretty heavy for them.
RPE will give us a good idea of how hard a set was, even if we don't think it should be that hard based on the weight on the bar. However, constantly training at RPE 9 or above and grinding through sets will lead to high fatigue accumulation, increased injury risk, possible burnout, and decreased motivation.
→ Training Load Progression:
The weight jumps from session to session should be appropriate for the lifter and the weight they're lifting. However, too big jumps can cause the RPE to increase quickly, technique breakdown, failed reps, fatigue accumulation, and increased injury risk.
Examples of appropriate load progressions are as a follows:
A 125lb female with a previous max of a 99-pound bench press is progressing her 5x3 on the bench press weekly. The relative intensity of the last two sessions has been around RPE 8. Appropriate weight increases per session would be 1 pound. More significant increases than that would likely be too large of an increase relative to her absolute strength.
A 185lb female with a previous max of 315-pound squat has progressed her 5x5 for the last two weeks. Things are still very easy. An appropriate weight increase per session for her would be a 5-pound increase. As the relative intensity of the 5x5 increases for a few weeks, the weight increment should be decreased to 2.5 pounds.
Training load progression should consider the volume per set, the number of sets performed, the demographic of the lifter, the relative intensity of the previous session, and other recent performances.
We don't recommend the "take what's their approach" where the lifter may add 20lbs just because they feel good that day. This approach has significant implications for future training. You can read more about our recommendations on RPE here and how to progress the training load here.
Training Session Organization:
The main barbell lifts should be prioritized and performed first during the workout. For example, suppose the lifter is squatting, benching/overhead pressing, and deadlifting in the same session. In that case, the lifts should be programmed in that order to allow the most athlete recovery and optimal performance within the training session.
Regarding the injured powerlifter, we might need to consider separating certain lifts that aggravate their symptoms. For example, someone with low back pain will likely benefit from performing squats and deadlifts on different days. Or suppose someone is having shoulder pain on the bench, also aggravated by squatting. In that case, they may benefit from squatting and benching on different days or benching before squatting.
For more information on exercise selection and prescription, check out this article.
Rest & Recovery:
A significant contributor to injury is accumulated training fatigue. The more acute or chronic fatigue we experience, the harder our training sessions become and the worse our performance is. This has implications for how much load we can lift and how well we can maintain our technique when executing the movements.
We want to assess athlete recovery within and across training sessions by looking at RPE, E1RM, and how much time they are resting between sets and training sessions. Check out this article for a complete understanding of fatigue management in barbell training.
How much rest a lifter is taking between sets should be appropriate for the RPE of their sets. If you notice that the RPE increases significantly from set to set, the lifter might be rushing and not resting long enough between sets. They probably need a program change if they're already resting for 5-6 minutes between sets. They shouldn't need to rest longer than that to be recovered for their next set.
Additionally, if a lifter is training more than four days per week and the training intensity on many of those days is above an RPE 8 on average, they do not have adequate time to recover between training sessions. Therefore, we recommend that most powerlifters do not barbell train more than four days per week and take at least one full day off per week from all exercise.
Recovery Assessment: Sleep quality, nutrition, and life/work stress all contribute to athlete recovery and fatigue. As rehab clinicians, we need to ask questions about these factors. This will help to understand the big picture and catch the details that the injured powerlifter might not think are contributing to their symptoms. Their training sessions should spread out throughout the week. While doing some back-to-back sessions is okay, we need to look at which training sessions are performed without rest days.
Sleep and nutrition play HUGE roles in recovery, so if the lifter isn't sleeping well or getting adequate nutrition, this should be addressed. The same goes for life stress, even when it seems far removed from training. Any life stress or emotional stress can impact sleep, nutrition, and performance, and it's not uncommon to see symptom exacerbation correlated to stressful life events.
We can't always change what's happening in their lives, but we can adapt the program to their needs as they change over time and through different stages.
Here are some questions to include in the barbell physical therapy evaluation of a powerlifter to assist in athlete recovery:
What did your training program look like a few weeks before and at the time of the injury?
Can you think of anything different around the time of the injury?
Do you wear any specific supportive equipment?
What specific lifts cause you symptoms?
Can you modify the range of motion or load to reduce symptoms?
How do you determine loads in a training session?
How high was the absolute and relative intensity in the weeks leading up to your injury?
How much sleep do you get regularly?
Do you know how much protein you're consuming daily?
Are you in a caloric deficit, surplus, or maintenance?
After the history, it's time to move on to postural and functional movement screenings. For the injured powerlifter, this will include an assessment of their barbell training techniques.
No matter what barbell exercise you perform or what technical model you follow, the nine elements we recommend assessing fall into two categories.
Balance:
Bar Path: Is the bar moving in a straight vertical line over the middle of the foot (or balance point)?
Joint Synchrony: Are the joints that are involved in moving the bar unlocking and locking at the same time?
Joint Neutrality: Are the joints not involved in moving the bar (aka the stabilizing joints) remaining as neutral as possible while the bar is moving?
Eye Gaze: Is their eye gaze fixed to one point in relative proximity to their body, and is their eye gaze set such that it's perpendicular to the line of their spine?
Force Transfer:
Rigidity: Are they creating and maintaining rigidity in all body areas before and during the lift?
Breathing: Are they performing the Valsalva optimally?
Muscle Utilization: Are they setting their stance and grip to utilize their muscles most effectively?
Range of Motion: Are they utilizing the most effective and efficient range of motion to maintain muscle tension and joint neutrality?
Speed of Movement: Is their movement speed consistent with the load on the bar and throughout the rep?
When it comes to the injured powerlifter, the real reason for their symptoms is usually related to their program, recovery, and sometimes inconsistent technique in combination with the former. Assessing these nine things can provide much information about how barbell training techniques interplay with their program and fatigue levels to support injury recovery or development.
Total training load, recovery, and technique must be assessed and addressed to help injured powerlifters resolve their symptoms in a manner that leads to long-term symptom improvement.
If you're looking for weakness in a specific muscle, you're likely barking up the wrong tree. When we do manual muscle testing, we're isolating muscles and asking them to be used in a way that they're never used in daily life or when a powerlifter is lifting heavy weights. So you'll likely find a muscle that appears weak, but that doesn't mean that it's the cause of their symptoms. Additionally, focusing on strengthening this particular muscle won't have significant carryover to the symptomatic lift. So it won't resolve their symptoms in the long run.
The rehab process for an injured powerlifter should be different from traditional Physical Therapy. The aggravating lifts SHOULD be included in their rehab program with modifications to intensity, volume, frequency, and technique as needed.
Think globally, not locally. Look at the training stress, fatigue, volume, and relative intensity on a session-to-session and weekly basis. Understanding these variables and using the barbell lifts as rehab rather than other modalities or exercises will significantly increase the success of a powerlifter's return to sport.
For more resources on how to improve your ability to work with injured powerlifters, check out our Clinical Coach Starter Kit and our article on tracking training trends. These tools will prepare you to successfully include barbell training as rehab of injured powerlifters, understand their program and training trends, and provide valuable recommendations.
Citations:
Horga, L.M., Hirschmann, A.C., Henckel, J. et al. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol 49, 1099–1107 (2020). https://doi.org/10.1007/s00256-020-03394-z
Romeo, V, Covello, M, Salvatore E. et al. High prevalence of spinal magnetic resonance imaging findings in asymptomatic young adults (18–22 Yrs) candidate to air force flight. SPINE: 44 (12) 872-878 (2019). doi: 10.1097/BRS.0000000000002961
Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High prevalence of superior labral tears diagnosed by MRI in middle-aged patients with asymptomatic shoulders. Orthopaedic Journal of Sports Medicine. (2016). doi:10.1177/2325967115623212