Table of Contents
3
Introduction
5
The Framework
6
Step 1: Analyze and Optimize Form and
Programming
10
Step 2: Change the Modifiable Factors
12
Step 3: Remove the Exercise and
Substitute a Similar Variation
14
Step 4: Re-introduce the Initial
Exercise and Rebuild
18
Bonus Section: Mental and Emotional
Variables
20
Bonus Section: The Psychology
of Building Work Capacity
21
Now What?
22
Frequently Asked Questions
24
Resources
2
Introduction
If you’re reading this, you’re most likely either a
fitness or rehab professional interested in
learning more about how to work with barbell
athletes, or you're a barbell athlete yourself!
Regardless, thank you for downloading this ebook. I hope you find it valuable.
My name is Dr. Michael Mash. I'm a Doctor of
Physical Therapy (DPT) and Certified Strength
and Conditioning Specialist (CSCS). I'm the
Owner and Founder of Barbell Rehab, a
company dedicated to helping improve the
management of barbell athletes.
Far too often, people don’t know what to do
when pain arises while training the squat,
deadlift, or bench press. Many may start
haphazardly foam rolling or performing
mobility work, in hopes that something will
provide relief.
I wrote this guide to put you on a better track … a
systematic track. So let’s talk about what you
can expect from this guide:
3
Goals
1. Learn why a systematic approach is the
most efficient method to overcoming pain
during barbell lifting
2. Understand exactly what to look for and
assess, and in what order, when pain occurs.
3. Learn how mental and emotional variables
factor into the pain experience
4. Understand the concept of optimizing the
mental aspect of returning to baseline
Common Issues this Guide
Can Help Solve:
1. Shoulder, back, hip, or knee pain with the
squat
2. Back pain with the deadlift
3. Shoulder or elbow pain with the bench press
or overhead press
What this WON’T Help Solve:
This is NOT a protocol for:
1. Tendinopathies. Tendinopathies require more
specific monitoring of symptoms
2. Healing acute muscle strains/tears
3. Rehabilitation of bone fractures or traumatic
injuries
4. To be taken as specific medical advice.
Without further ado, let’s get started!
4
The Framework
Pain is a complicated experience
Filled with feelings of fear, stress, and anxiety, it
can be scary when pain arises during a barbell lift.
While I ALWAYS recommend getting a formal consult from a qualified medical professional to rule
out more serious conditions (preferably one that
understands the nuances of barbell training), this
guide will serve as a framework to help set you on
the correct path.
This 4-step approach is based on
the principle of priority
For example, when pain arises, the first plan of
action you should take is Step 1 (shown below).
Step 1 represents the epitome of interventions
that should be addressed prior to any other intervention. If you still have pain after step 1, then you
should move on to step 2, etc. Here is the step-bystep framework
5
Step 1: Analyze and
optimize form and
programming
Form
The first step you should take when pain arises
during a compound lift such a squat, bench, or
deadlift is to analyze the form. Sometimes all this
takes is a self-critique of videoing yourself
performing the lift from multiple angles. In some
cases, the input of a qualified coach can be
extremely beneficial as well.
For help with form, check out our video tutorials
of the basic barbell lifts:
Squat
Bench
Deadlift
Overhead Press
6
Why do I recommend analyzing form first? Well,
it wouldn’t make sense to switch to a different
variation of a squat if you’re low bar squatting
with the bar in the incorrect position. Additionally,
it wouldn’t make much sense to change the grip
width of your bench press if you’re not keeping
your shoulder blades squeezed throughout the
entirety of the lift.
This is why you must first OPTIMIZE the form of
the barbell lift prior to making any other
changes!
For the bench press this may include, as mentioned, keeping your shoulder blades retracted,
avoiding flaring the elbows too much, and making
sure you’re using sufficient leg drive.
For the squat, this may include ensuring you’re not
allowing the knees to cave in excessively or
allowing the heels to rise off the ground.
Often times, pain with the barbell lifts can be
eradicated simply with optimal coaching!
Additionally, with form adjustments, you’ll likely
have to decrease the load as well. This will allow
you to practice the lift, with your refined
technique, and begin to build up your work
capacity again.
To make sure you’re hitting the key points of each
form, feel free to download our form checklists for
these lifts as well.
Squat
Bench
Deadlift
Overhead Press
7
RPE Scale
Programming
In addition to optimizing form, I recommend
assessing the programming of the lift prior to
making any other modifications. For example, it
may not be a grip width issue on the bench;
maybe your programming is too much for YOU
and adjusting the volume or intensity can resolve
the issue! This is why we place programming and
form at a level ABOVE the modifiable factors such
as adjusting grip width.
Are you consistently grinding out reps, taking multiple sets to failure, and even missing reps?
Are all of your working sets completed at high
intensities in the RPE 9-10 range?
No amount of form modification can help with
this … this is a load management error!
Ideally, the majority of your training should occur
in the RPE 7-8.5 range. This is enough of a training
stimulus to increase strength and hypertrophy but
minimize injury risk.
For more information on RPE, check out this
article HERE.
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Force Adaptation, Limit Fatigue
Overall, the goal of training is to induce enough
of a stimulus to disrupt homeostasis while
simultaneously limiting the negative
consequences such as injury and excessive
fatigue. While the untrained lifter can usually
tolerate slow increases in load every workout
without increased risk of injury, intermediate
and advanced lifters require further
manipulation of training variables.
So as you can see, we place the “programming”
tenant as a top-level priority component of our
four-step model for training with pain.
Optimization of form and programming should
be made FIRST prior to any other intervention.
9
Step 2: Change the
Modifiable Factors
If you are still having pain after optimizing your
form and programming, the next plan of action
would be to change the modifiable factors.
What are modifiable factors?
Modifiable factors are physical variables of a
lift that you can alter that can help change your
body’s pain perception. Making slight form
adjustments to the barbell lifts can help offload
sensitized structures and allow you to continue to
train in a tolerable fashion. Examples of
modifiable factors for the major barbell lifts
include:
1.
2.
3.
4.
5.
Stance width during the squat and deadlift
Degree of toe out during the squat and deadlift
Tempo of the lift
Grip width of the bench press or overhead press
Range of motion of the lift
10
For example, sometimes all it takes to alleviate a
hip “pinching” sensation at the bottom of a squat
is to adjust the stance width and toe out. I’d hate
to see someone completely ditch a barbell back
squat from their program due to hip pain prior to
making this adjustment! For more information on
how to handle hip pinching at the bottom of your
squat, check out the article here.
In other cases, such as knee pain during the squat,
slowing the tempo down can help both mitigate
symptoms AND drive adaptation.
If small alterations in form don’t alleviate your
pain, you can also change the range of motion of
the lift.
This may include performing variations like partial
squats or pin squats if you have pain at the bottom
position of the squat.
Another example would be performing board or
floor presses if you have pain at the bottom position of the bench. For more information on how
to address shoulder pain during the bench press,
check out the article here.
The overall idea here is to make SLIGHT modifications to help control pain, but still obtain a training
effect to limit deconditioning.
Alterations of modifiable factors are placed in step
2 of this model because you should only go this
route once the programming and form has been
optimized.
If, despite various changes in modifiable factors, you still experience
pain, it’s time to move onto step 3
11
Step 3: Remove
the Exercise and
Substitute a Similar
Variation
If you still have pain after being
properly coached, optimizing programming, and changing the modifiable factors, it may be time to
temporarily avoid the provocative
exercise.
Temporarily removing the provocative exercise
will allow the specific movement pattern
to “desensitize” and then you can train a similar
movement to continue to elicit a training effect.
For example, if you continue to have back pain
with a low bar squat despite optimizing form,
programming, and making modifications in stance
width and tempo, temporarily switching to a high
bar squat or front squat for 4-6 weeks may allow
you to train the squat pattern pain-free. You can
continue to achieve a training effect and limit
deconditioning by training a similar variation, while
allowing the aggravating movement (low bar
squat) to desensitize.
Sometimes the squat pattern itself is so sensitized
that you may need to switch to dumbbell lunge
variation such as a reverse lunge, split squat, or
rear foot elevated split squat.
For the complete guide to acute low back pain,
check out the article: “I Hurt My Back Lifting
Weights...Now What?”
12
Here is another example of removing
a sensitized exercise in the case of
shoulder pain with the bench press.
If you still have pain after ensuring form and
programming is optimized, and you tried to alter
grip width, load, or tempo, you can try doing a
low incline barbell press or flat dumbbell press
instead. The slightly different mechanics of the
dumbbell press will help you continue to train in a
tolerable fashion while allowing the highly
sensitized movement (barbell bench press) to
calm down.
Removing the aggravating exercise should be a
last resort and only used after all other options
(i.e. proper coaching, programming, and making
modifications) have been exhausted. That’s why
we place this at step 3. But we can’t do this
forever ...
Once you have 4-6 weeks of tolerable training
with the lift variation under your belt, it’s time to
re-integrate the original, once painful
movement and linearly progress from there. This
leads to the final step 4!
13
Step 4:
Reintroduce and
Rebuild
If your goal is to get back to a pain-free bench
press, you can’t avoid the bench press forever!
There must come a time where we have to
reintroduce the once provocative exercise and
build back up to baseline!
Enter Step 4
Common questions barbell athletes have when
reintroducing a once painful exercise include
the following:
1.
2.
3.
4.
5.
How much weight should I start with?
How many reps should I do?
How frequently should I train the lift?
How should I increase the load?
What happens if it starts to hurt again?
These are all valid questions! What I’m about to
share with you is my preferred approach and
the exact approach when teach in our live
Barbell Rehab Method Certification course.
Although there’s more than one way to safely
do this, including different rep ranges and
frequencies, I’ll provide a rationale as to why I
prefer this specific approach.
How much weight should I start
with?
When reintroducing a once painful lift back
into your lifting routine, I prefer to set the initial
intensity of the working sets at a load that is
pain-free or tolerable. This is often at a rate of
perceived exertion (RPE) of 5 or less.
14
For example, if you were squatting 315 lbs. x 5 prior to
removing this exercise, upon re-integrating the squat, I’d
recommend starting at 3 sets of 5 at 135 lbs. The main goal
here is to introduce a stimulus that your brain and body
perceive as healthy and non-threatening, and the key to
this is to make sure it’s light enough! Here’s another
example: If you were benching in the 200s, I would start
the working sets around 95 lbs. for 3 sets of 5.
How many reps should I do?
When it comes to rehabbing the barbell lifts, I prefer sets in
the 4-6 rep range. While sets in the higher rep ranges
(10-15) may be advantageous in specific rehab scenarios
like tendinopathies, I don’t see them as beneficial when the
goal is to return to the squat, bench, or deadlift. Higher rep
sets can induce excessive fatigue, allow more room for
form breakdown, and are not as optimal for progressively
increasing intensity (load).
How frequently should I train the lift?
When rehabbing the basic barbell lifts, I prefer a training
frequency of 2-3x/week. Because you will be utilizing a
lower intensity and RPE, training at a frequency of 1x/week
is not enough to drive an adaptation. Conversely, training
the lift 4-5x/week is usually too frequent of a stimulus
after a period
15
of avoidance that the body could begin to perceive it as harmful again. 2-3x/week is usually
the sweet spot to achieve a sufficient
adaptation, yet ward off the return of symptoms.
How should I increase the load?
Now that you know that you should start your
first day back at a relatively low intensity,
utilizing the 4-6 rep scheme, training the lift
2-3x/week, the question remains … how do you
progress the load? When returning to a once
painful barbell lift, I recommend starting at light
weight and just adding weight to the bar every
single session (in other words, linearly increasing
intensity) Why?
Because you’ll be starting at such a low
intensity, that this will be possible for a while
before the sets start to become too grueling.
The exact amount for the weight jumps from
session to session is going to vary based on the
lift and the person, but it can start anywhere
between 5-20 lbs a session. For someone who
was once able to deadlift 600 lbs, and is starting
their rehab programming at 135 lbs, 20lb
increases may be feasible at first. For a female
who benches in the low 100s and is starting at
45 lbs, 5 lb increases from session-to-session
may be appropriate.
You want to work on slowly increasing
intensity until your working sets become an
RPE 8-8.5. When you get up to a consistent RPE
8-8.5 on your working sets, this would warrant a
program change to drive further progress and
reduce injury risk.
So let’s be clear. You should NOT run a linear
progression to failure.
16
I recommend increasing intensity only (not
number of sets) as a way to incrementally
increase tonnage and thus build your work
capacity to establish a solid chronic training load.
What Happens if Pain Arises?
Even when accounting for variables such as
load, frequency, and intensity, rehab is rarely a
simple game. Often, even in an effective rehab
program, you may experience symptoms (pain)
upon reintegrating a barbell lift. When this
happens, I suggest the following:
1. If pain is present during a warm-up set but
disappears with the working sets, proceed
forward.
2. If pain is not present during a warm-up set
but appears with the working sets, perform
more sets just below the painful load.
3. If pain is present during a warm-up set and
WORSENS with increased load, the barbell
lift may still be too symptomatic to proceed
forward with. Continue training a different
modification for 4-6 weeks and try to
reintegrate this lift after.
Overall, training with a little bit of pain is ok,
provided it dissipates shortly after the training
session and is back to baseline 24 hours after.
As you can see, there are many variables when
it comes to rehabbing the barbell lifts, and
everybody’s presentation will be different. While
this guide will provide you with a general
framework, I’ll always recommend a formal
consult with a qualified medical professional to
obtain a plan unique to you.
17
Mental and
Emotional Variables
Pain is a complex multidimensional
experience encompassing
biological, mental, and cultural
variables.
Far too often, when rehabbing a barbell based
injury, many will only focus on the “biological”
aspect. Biological factors include many of the
variables we already discussed including external
load (intensity), volume, frequency, and form
mod-ifications. While these factors are certainly
import-ant and should be closely monitored in the
rehab process, they aren’t the ONLY factors.
In many cases when pain arises during a lift, it
may not be a “biological” load management error,
but a “psychosocial” load management error. Let
me explain.
You could have an optimally dosed resistance
training program, but start to experience pain on
the week of your college finals, or when you’re
experiencing another personal stressful event.
Stress levels, poor sleep, poor diet, increased
anxiety/depression, and lack of social support
can ALL contribute to the pain experience!
Your healthcare provider should always obtain a
full history and ask you about the different
psychological variables.
18
Often, psychosocial variables are influencing
the pain experience.
In this situation, if you believe a “flare up” is
psychosocially driven, it is especially important
to pay attention to your RPE.
A specific weight may feel
heavier than usual on these
days...and that’s ok!
It doesn’t mean you are getting weaker, but
these aren’t the days to push things!! A few
days without adding weight to the bar is NOT
going to adversely affect your progress long
term.
Limiting the intensity during this situation and
really zoning in on the RPE are usually all that
are needed to limit deconditioning during
stressful times. Then, it’s time to slowly ramp it
back up after the flare up has subsided.
19
The Psychology
of Building Work
Capacity
A vital part of the rehab process is
having realistic expectations
Far too often, those who are training through
pain are consistently training to set and break
person-al records (PRs). This can lead to a
vicious cycle of consistent and repetitive pain
“tweaks.” For example, you may be dealing with
repetitive back “tweaks” from deadlifting.
In cases like this, continuing with your
prescribed performance program may not be
ideal.
Again, a few days without adding weight to
the bar is NOT going to adversely affect your
prog-ress long term!
Instead, you need to switch your mindset to
training with the purpose of controlling
symptoms and building work capacity vs.
chasing PRs. Temporary lowering the RPE is a
great solution to control symptoms, work on
returning to a pain-free baseline, and then start
chasing performance based goals!!
20
Now What?
Thank you for reading this book!
I hope you found the information useful and hope it helps
you or your clients train more effectively.
Remember, this is a step-by-step approach!
You should exhaust all options in step one before moving to
step two, and so on. The steps are specifically formulated in
a hierarchy that promotes a systematic approach to lifting
with pain.
If you are a fitness or rehab professional and interested in
learning more, check out our CEU approved courses. We are
currently teaching our live Barbell Rehab Method
Certification event at gyms all across the United States and
also have 4 self-paced online courses to help you level up
your fitness and rehab game!
Click here to learn more about our courses
21
Frequently
Asked Questions
I have been diagnosed with a quad
tendinopathy. Will this template
work for me?
While an effective tendinopathy protocol will still
follow this 4-part template, this specific concern
usually requires a more thorough manipulation of
training variables outside the scope of this
product
I strained my hamstring. Will this
template work for me?
No. Acute muscle strains are outside the scope of
this framework as well.
Should I be stretching and foam rolling in my warm-up to help alleviate
symptoms?
Generally no. If they are already an established part
of your routine and they feel good, then by all
means keep doing them. But, stretching and foam
rolling aren’t necessary to either treat or reduce risk
of injury. I recommend a dynamic warm-up instead.
Where can I learn more?
If you are a fitness or healthcare professional,
consider attending our of our CEU live courses or
online courses. More information can be found
here.
If you're a barbell athlete, we recommend going
through the "Blog" section of our website and
watching our information YouTube videos here.
Both will help you for free!
22
About The Author
Hi, my name is Dr. Michael Mash. I’m
a Doctor of Physical Therapy, and a
Certified Strength and Conditioning
Specialist.
We teach fitness and rehab professionals how to
improve the management of barbell athletes
through live and online courses. Our courses are
approved by the NSCA, NASM, ACE, ACSM, BOC,
ISSA, and for Physical Therapists and PT
Assistants.
Click here to see a current list of live events.
23
Resources
CEU Approved Courses for
Fitness and Rehab Professionals:
Live and In-Person
The Barbell Rehab Method Certification
Self-Paced Online
The Barbell Rehab Workshop
Strength Training the Post-Operative Client
Low Back Pain Fundamentals Online Course
Unique Considerations for the Female Barbell
Athlete
@barbellrehab
Facebook
Youtube
michael@barbellrehab.com
**Medical Disclaimer: Please check with your primary care physician before starting a
training or exercise routine. By employing the recommendations described here, you
agree and understand that all the advice, tips, and content are taken at the user’s own
risk. This information is not intended to diagnose any medical condition or to replace
your healthcare professional. Consult with your healthcare professional to design an
appropriate exercise prescription. If you experience any pain or discomfort with these exercises, stop immediately and consult your healthcare provider. Barbell Rehab, LLC and
Michael Mash make no representations as to the accuracy of the information on links on
this site. The owner will not be liable for any errors or omissions in the information provided nor will the owner be liable for any accidents or other damage.
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