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What If Pain Or Injury Stands In The Way?

We all have some level of understanding of how to progress a movement or exercise. Making progressions is necessary for progressive overload and the desired adaptations needed to elevate whatever training goal or athletic feature you desire. Typically we make progressions based off three different areas:

1) Skill Level: If an athlete performs a movement pattern flawlessly, in what ways can we challenge them further?

2) Strength Level: If an athlete has adapted to this load, is it safe to say we can add some external load and continue the overall intent of the movement free of compensations?

3) Readiness Level: If volume or fatigue has accumulated, has the person or athlete reached a healthy level of fitness to perform this demanding movement?

But when the inevitable ache, pain, or even injury stands in out way; how do we keep people moving without losing sight of the INTENT of the programmed movement?

Our fist step is distinguish INJURY versus RESTRICTION?

Injury: Physical trauma and damage has occurred that impedes bodily function. Examples include an athlete suffered a Grade 2 Ankle Sprain and now not tolerate weight bearing on that foot. An older adult sustained a rotator cuff tear throwing that awkward bag over their shoulder at home and now can not raise their arms overhead. Function has been compromised.

Restriction: Soreness, pain, fatigue that may or may not limited the desired movement pattern and/or training session. Examples include the day before squatting you did bent over barbell rows and now your lower back is fatigued and sore. You didn’t take a rest day and you’re approaching your 4th upper body day in less than 7 days and you feel sore and tight. Or every time you lunge forward you notice some mild discomfort in the anterior knee and you’re supposed to train lower body today.

For the sake of this article we will classify limitations, both injuries and restrictions based on different body regions.

1) Ankle/Foot and sometimes Knee

2) Spine (primarily lower back)

3) Upper Extremity (shoulder, elbow, hand)

The most important concept is how you individualize the program without sacrificing the intent and integrity of the movement pattern, skill development, and overall program design. I have taken four of the more common lifts and broken them down into practical ideas and ways you can regress them:

If you have an ankle restriction the deadlift is gonna be one of your go to training movements to begin with. But you can further decrease the ankle demand by performing an RDL or pin pull variation. You can always use a single leg variation as well just as with landmine or bench supported(if balance is an issue) or true single leg RDL.

For those with athletic low back pain, back soreness, or other spine limitations the reverse hyper is both a treatment and a loading strategy! Do not underestimate the utility of this movement. For those of you without a fancy reverse hyper machine you can rig one up by placing an exercise ball on a bench.

For those with upper extremity limitations that limits the gripping and pulling motion with a deadlift, a novel stimulus may be needed here through a suitcase deadlift (deadlift using load on one side) so we demand more midline stabilization and trunk control through anti side-bending and anti-rotation (two key traits that may not get training as much as needed). The hands free deadlift is one where we have the load supported around out neck as chains are attached to the barbell. We still use the same spinal stabilizers and hip prime movers it just takes the demand of the entire upper extremity out of it. The barrier to entry for this one is high because of the set up AND equipment needed to perform safely but its a very viable option if you have to train the deadlift in a more specific manner. You will either find a way or find an excuse. There is ALWAYS a solution or modification that is appropriate.

With an injury we may have someone who is partial or even non weight bearing. So that will be tougher to modify. A single leg squat variation like the skater squat is a great resource as long as they don’t lose control and potentially disrupt post surgical healing on the involved lower limb. For those with knee limitations we can hinge a bit more or use a box to focus on keep the shin more vertical to decrease the knee forces and stress.

If the limiting factor is the spine then the belt squat is the first modification we like to use. If you do not have access to a belt squat you can create a homemade one.

For those with arm and shoulder limitations, the safety bar is the gold standard. A hatfield squat is another great option!

For shoulder issues vertical pulling and pulling will be the biggest pattern to likely avoid and train around. We still have a plethora of horizontal pushing and pulling at our disposal to work with. The block or board press AND floor press are great ways to limit shoulder stress and ROM while still loading the target musculature.

The most magic tends to happen when we alter grip position for those with sticky shoulders. For example instead of bench pressing with a pronated (standard) grip we can use a more neutral grip in using a DB or a Kadillac Bar HERE.

For the painful elbow we can modify angles more so than positions. For example someone may have heavy pain with a flat horizontal pressing motion but if we make it more inclined to reduce load on the elbow we can work around that.

For the lower back we can utilize a half-kneeling position to help avoid excessive lumbar extension for most pushing and pulling movements. For those with lower back issues a floor press or a modified bench press keeping the feet on the bench or using plates avoid excessive hip flexion end ranges which may further irritate the lower spine.

Olympic weightlifting movements are the most critical to regress and modify because they are plyometric in nature so there’s a more forceful impact and ground reaction forces. They also require more ankle mobility so those with ankle and foot restrictions should be quick to regress. As long as you train with the same intent of “moving quickly and powerfully”, the KB Swing is a tremendous replacement with requires very little ankle mobility.

For those with spine issues or lower back pain the hip thrust is a tremendous way to address a hip hinge and posterior chain with compromising symptoms and tissue healing. You can keep the same intent by moving explosively through the concentric motion of the movement.

For those with upper extremity injury or limitations you can always perform a unilateral movement with a DB. Mechanical loading may not be the same as a barbell, but the coordination challenge from this upper unilateral variation will be worth the sacrifice. Plus latest research and science tells us that we have cross training effects so you may even get some benefit on the contralateral side. No excuse to not train!


If the restriction is severe enough that it doesn’t allow bilateral load, then a single leg variation will become necessary. Be careful when choosing your variations. For example having the painful leg behind you when doing a RFE squat can cause knee irritation because of the eccentric demand and lengthening position. The landmine is an infinitely scalable movement that can be used to work around just about any injury or restriction. You can find a landmine attachment HERE.

Most modifications will be determined by one of two things

What aches, pains, or injuries are jeopardized with movement patterns that use those regions as secondary stabilizers or even primary movers.

What equipment is available to use?

This is not meant to be a cookie cutter approach to guide you following acute injury or restriction. It’s just a simple approach to stay moving and help you adjust your programming on the fly. Pain is a warning signal which helps YOU get ahead of it before it turns to a chronic issue or significant injury. Pump the breaks, back off a little and seek a medical professional when things feel painful. Use that period to address primary causes of pain that maybe you have been avoiding or delaying and come back stronger. The worst thing you can do is run in place. Taking a few steps backwards may give you a better position to move forward with less disruptions.


Dr. Bryan Keith

Myomuv PT

We help active adults and athletes return to the activities they love without pain, without taking time off, and feeling more confident and capable than ever before.