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EVIDENCE-BASED ALTERNATIVES TO
POPULAR EXERCISES
by David Michael Jett, Jr., M.S., C.S.C.S., EP-C, PN; Jessica Gibb, M.S., CEP, EP-C, FMSC; and
David E. Verrill, M.S., RCEP, CEP, PD, FAACVPR
Apply it!
Exercise selection for fitness clients
is often based on tradition and experience of the fitness professional.
With the growing prevalence of
acute and chronic musculoskeletal
injury, exercise selection practices
should be updated and diversified
to accommodate a diverse population. Evidence-based alternative exercises are presented for several
traditional movements commonly
used by fitness enthusiasts. These
alternative exercises can be performed with minimal risk while promoting similar, and in some cases
more beneficial, training effects.
Key words: Overuse Injury, Low
Back, Shoulder Impingement,
Fitness, Musculoskeletal
INTRODUCTION
T
he selection of client-appropriate exercises can be a challenging task for a
fitness professional. For the novice fitness professional, exercise selection
often is based upon exercises from textbooks or exercises that the individual has seen other trainers/trainees perform. In both cases, there may be
alternative exercises for the fitness professional to use that better serve their
client. When working with a client base that may be prone to chronic injury, as a growing
number of middle-aged adults seem to be, alternative, evidence-based exercises may be a
way to prevent injury. In 2013 alone, there were more than 10 million individual doctor’s
office visits for both lower back pain and shoulder symptoms (28).
Because overuse injuries can be difficult to diagnose, treat, and recover from (8), the task
of safe and proper exercise selection becomes more important and may even assist with prevention of overuse injuries. Evidence exists indicating several exercises that were once fitness
standards are now believed to either initiate a novel injury or exacerbate an existing injury
(1,4,8–11,13,14,17–22,24–27). We have identified two anatomical locations — the shoulder
joint complex and the lumbar spine — where the combination of previous injury and
inappropriate exercise selection may escalate potential soft tissue damage. In an effort
to avoid such a combination, it may be beneficial to select more modern, evidencebased alternative exercises, as opposed to some of the traditional fitness standards
mentioned hereinafter.
Because overuse injuries can be difficult to diagnose, treat, and
recover from (8), the task of safe and proper exercise selection
becomes more important and may even assist with prevention of
overuse injuries.
One area where the incorporation of alternative, evidence-based exercises may be of
particular importance is the shoulder joint complex, due to this joint's relative importance
for sporting activities and activities of daily living. Historically, exercises used to train this
area often produce torque in extreme ranges of motion (ROMs), leading to shoulder capsule stress or nervous and ligament impingements (3,8,11,13,26). Some examples include
the behind the neck lat pulldown, behind the neck shoulder press, and triceps bench dips.
Specifically, an increased risk of anterior capsule instability, suprascapular neuropathy,
and rotator cuff impingement has been shown with both the behind the neck lat pulldown and shoulder press (8,11,13,26). In addition, an increased risk of impingement
syndrome and posterior capsule stress has been shown with triceps bench dips (8,11).
As shown in the Table, there are several evidence-based alternative exercises that can
illicit similar, if not better results, and do so with a decrease in risk of injury. For both the
20
ACSM’s Health & Fitness Journal ®
November/December 2017
Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
TABLE: Benefits of Alternatives to Popular Exercises
Popular Exercise
Risks
Alternative Exercise(s)
Benefits
BN lat pulldown
1. External rotation with abduction
of glenohumeral joint through
extreme ROM, exacerbated by
horizontal abduction to avoid bar
to head contact (8,11,13,26)
A. Can lead to the following:
- Rotator cuff instability (26)
- Glenohumeral ligament
stress (26)
- Suprascapular neuropathy (8)
- Rotator cuff impingement (13)
- Stress anterior capsule (11)
2. Extreme cervical spine flexion and
forward head tilt (8,11,13,25)
A. Can lead to the following:
- Transient upper extremity
paralysis (11,13)
- Transient brachial plexus
nerve injury (8,13)
1. Anterior lat pulldown (8,11,13,
25,26)
A. Performed in the scapular
plane (8,11,13,25,26)
B. Arms at 30-degree angle
forward (8,11,13)
C. Torso reclined at 30 degrees
(13) (See Figure 1)
1. Better emphasis on lattimus
dorsi, shoulder adductor, and
scapular retractor muscles
A. BN places more stress on
elbow flexor complex (11,13,
25,26)
2. Eliminates risk of shoulder
instability and anterior
glenohumeral stress (11,13)
3. Better mechanical advantage,
which allows for greater weight
to be pulled (13,25)
4. Better sport specific
applications (26)
BN shoulder press
1. Repetitive abduction and
external rotation producing
torque in extreme ROM (8,11,13)
A. Can lead to the following:
- Suprascapular neuropathy (8)
- Significant strain on
anteroinferior glenohumeral
ligaments (13)
- Anterior capsule instability (11)
2. Stresses cervical spine because
of excessive flexion in overhead
position (13)
1. Anterior shoulder press
(8,11,13)
A. Arms at 30-degree angle
forward (8)
B. Performed in the scalpular
plane (8,11)
1. Allows weights to be positioned
in body’s center of gravity
throughout lift (13)
2. Equal combination of shoulder
flexion and abduction during
concentric phase (13)
3. Assures shoulders avoid at-risk
position throughout (11)
4. Better sport specific
application (13)
Triceps bench dips
1. Shoulder flexion performed with
extreme internal rotation when
arm reaches 90-degree angle (8)
A. Can lead to the following:
- Impingement syndrome (8)
- Inflammation of subcoracoid
bursa for friction with lesser
tubercle, causes compression
of surrounding soft tissue (8)
2. Posterior glenohumeral stress
when weight borne through arm
with shoulder and elbow flexion (11)
1. Traditional or modified
push-up (3,15) (See Figure 2)
2. If posterior shoulder capsule is
already unstable, body weight
exercises may need to be
avoided all together. Use a
triceps cable machine pushdown
as an alternative (8,11)
1. Appropriately strengthens
scapular stabilizing muscles,
such as the serratus anterior
2. Shown to have better activation
of scapular stabilizing muscles
than other exercises (3,15)
3. Enhances shoulder joint muscle
activation (15)
4. Strengthening of shoulder
stabilizers plays a role in
rehabbing various shoulder
pathologies (3)
Hurdler’s stretch
1. May cause strain in the groin
(20,27)
2. May cause laxity of the medial
ligament of the bent knee and
put stress on the ligaments of
the knee joint (19,20,27)
3. May stress the cartilage of the
bent knee (19,20,27)
1. Semistraddle (modified hurdler’s
stretch) (7) (See Figure 3)
2. PNF hamstring stretch (2)
1. Does not force extreme internal
rotation of the bent leg (27)
2. Does not induce medial stress
on the ligaments/cartilage of
the bent knee (9,27)
3. If available, PNF may be superior
as it promotes muscular
inhibition (2)
(continues)
Volume 21 | Number 6
www.acsm-healthfitness.org
Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
21
EVIDENCE-BASED ALTERNATIVE EXERCISES
TABLE: Benefits of Alternatives to Popular Exercises (Continued)
Popular Exercise
Risks
Alternative Exercise(s)
Benefits
4. May cause discomfort at the hip
joint because the femur of the
leg that is tucked behind is in a
position of extreme rotation of
the joint angle (20,27)
Loaded lumber
rotation (e.g., Russian
twist)
1. May cause/exacerbate
degradation of intervertebral
disks (21)
2. May be more dangerous when
combined with lumbar flexion
(10,14)
1. Lateral cable press (24) (See
Figure 4)
2. Anti-rotation chop (See Figure 5)
1. Torsional challenge(s) that
require the resistance of
rotation and therefore lumbar
stability as the arms are moved
in different planes (24)
2. Trains core stability, specifically
rotary stability, which will assist
in producing and integrating
force in the limbs (16)
Loaded lateral flexion
(e.g., dumbbell side
bend)
1. Repeated flexion increases
likelihood of disk herniation (4)
2. Lateral bending with compression
may produce disk herniation (1)
1. Side plank or modified side
plank (24) (See Figure 6)
2. Asymmetric loaded carry (24)
(See Figure 7)
1. Trains the QL and lateral
musculature (24) to assist in
creating a stable base (16) for
limb motion
2. Side plank improves trunk
endurance without producing
low back pain (12)
3. Isometric training superior to
dynamic training for improving
core stiffness (18)
Straight leg sit-ups
1. Lumbar strain by not able to fully
engage abdominal muscles
2. Increases stress on the low
back muscles because of activity
of the muscles that flex the hip
(20,22,25)
3. Stretches abdominal muscles that
may already be too long and weak
4. May result in nerve impingement
and compression, as well as
compression on the disks (19)
1. Bent knee sit-ups with arms
folded on the chest (20,25)
2. Prone elbow plank (See Figure 8)
1. Helps stabilize the pelvis
2. Supports a neutral spine
3. Improves neuromuscular
efficiency and intervertebral
stability (5)
4. Strengthens rectus abdominus
with less stress on the lumbar
musculature
Alternating crunches
1. May cause hip flexor strains
2. Strains the neck muscles and puts
pressure on the cervical spine (20)
3. Hyperflexion of the neck
4. Aggravation of already thin disks
in arthritic conditions (19)
1. Partial curl-ups with knees bent
and hands across chest, with
curling up motion until scapulae
leave floor (19,20)
2. Prone elbow plank (See Figure 8)
1. Less neural activation of hip
flexors and ancillary muscle
groups that are not the focus of
the exercise
2. Better pelvis stabilization
3. Reduced stress on cervical spine
Back hyperextension
or “Superman”
1. Extended posture results in
intervertebral disk loading (23)
2. Lumbar region bears a high
spinal compressive load as a
result of the bilateral muscle
activity. The load is transferred
to the vertebral joints and can
also crush the interspinous
ligaments (23)
1. Single leg extension load with
one knee on mat and rear leg
and opposite arm extended
(bird dog) (23) (See Figure 9)
2. Floor cobra exercise in a prone
position with hips on floor, arms
extended straight backwards,
and toes pointed downward
resting on floor (6)
1. Single leg extension exercise
creates minimal external loads on
the spine yet produces an extensor
moment (and small isometric
twisting moments) that results
in extensor muscle activity (22)
2. Floor cobra exercise promotes
isometric strengthening of
gluteus maximus, hip flexors,
and erector spinae
BN, behind the neck; PNF, proprioceptive neuromuscular facilitation; QL, quadratus lumborum.
22
ACSM’s Health & Fitness Journal ®
November/December 2017
Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
behind the neck lat pulldown and shoulder press, moving arms
to 30 degrees forward in the scapular plane is suggested as a
safer alternative. In addition, this placement allows for greater
weight to be lifted, better mechanical advantage, and increased
sport specificity (8,11,13,25,26). With respect to the triceps
bench dip activity, there are two alternatives suggested within
the research. First is a traditional push-up or modified pushup. By adjusting to this exercise, shoulder stabilization muscles,
such as the serratus anterior, are better activated and strengthened (3,15). Second, it is suggested that if a client has any previous posterior shoulder capsule instability, body weight exercises
are not recommended and a triceps pushdown exercise on a cable machine is the recommended alternative (3,8,11,15).
A second anatomical area for which exercise selection may be
important for injury prevention is the musculature surrounding
the lumbar spine, popularly known as the “abs.” Exercises used
to train this area often focus on dynamic efforts of lumbar extension, flexion, lateral flexion, and rotation — and these movements may or may not be loaded. The names of these exercises
are familiar — the Russian twist (loaded lumbar rotation), the
dumbbell side bend (loaded lateral flexion), straight leg sit-ups,
alternating crunches (both lumbar flexion), and back hyperextension or “Superman” (lumbar extension). Evidence indicates that these exercises may exert one or multiple stressors
on anatomical components of the lumbar spine. Specifically,
interverbral disks are at increased risk of degradation during
Photos courtesy of Frank Muntis, Greta Cesarz, and University of Louisville Student
Recreation Center.
Figure 1. Anterior lat pulldown.
Volume 21 | Number 6
loaded lumbar rotation (21), increased risk of herniation during
loaded lateral flexion (1,4), and increased compression during
the straight leg sit-up exercise (19). In addition, ligaments within
the spine may receive undo stress during repeated lumbar extension exercise (23).
It is generally understood that the primary purpose of muscle is
to produce joint movement, with a secondary purpose of joint stabilization. However, with respect to the core musculature (erector
spinae, rectus abdominis, internal and external obliques), some
exercise authorities believe that these functions should be reversed. McGill (24) asserts that the purpose of these muscles is
to prevent motion rather than to produce motion, and Kibler
et al. (16) contend that a well-conditioned core functions as a
rigid cylinder that promotes lumbar spine stiffness. Consequently, these fitness professionals feel that core training programs should focus on static exercises that emphasize lumbar
spine stability rather than on dynamic exercises that enable lumbar spine movements such as trunk flexion, trunk extension,
trunk lateral flexion, and trunk rotation (Table).
It is generally understood that the primary
purpose of muscle is to produce joint movement,
with a secondary purpose of joint stabilization.
However, with respect to the core musculature
(erector spinae, rectus abdominis, internal and
external obliques), some exercise authorities
believe that these functions should be reversed.
Although the authors recommend static exercises to enhance core stabilization, we realize that many fitness trainers,
trainees, and enthusiasts may choose to perform more traditional dynamic exercises.
Therefore, we have included the best evidence-based versions
of these two particular exercises to minimize injury risk for individuals who desire to use these movements. In addition, because
low back pain is one focus of this article, and low back pain often
is partially addressed by focusing on the improvement of hamstring flexibility, we have included a commonly used hamstring
Figure 2. Traditional push-up.
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Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
23
EVIDENCE-BASED ALTERNATIVE EXERCISES
Figure 4. Lateral cable press.
Photos courtesy of Frank Muntis, Greta Cesarz, and University of Louisville Student Recreation Center.
Figure 3. Semistraddle/modified hurdler’s stretch.
Figure 5. Anti-rotation chop.
stretch (the hurdler’s stretch), its potential risk, and an evidencebased alternative to this commonly used stretch (Table).
CONCLUSIONS
The process of appropriate program design can be complicated,
but this practice can be simplified somewhat by considering the
removal of specific exercises that may be inappropriate for many
populations. Evidence was presented in this article to support
the replacement of several exercises due to increased injury risk
(1,4,8–11,13,14,17–22,24–27). Evidence-based alternatives to
each movement were recommended and described. These
Figure 6. Modified side plank.
24
ACSM’s Health & Fitness Journal ®
November/December 2017
Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Figure 8. Prone elbow plank.
Photos courtesy of Frank Muntis, Greta Cesarz, and University of Louisville Student Recreation Center.
Figure 7. Asymmetric loaded carry.
alternative exercises promote a similar, or in some cases, more
beneficial training effect and also have a low injury risk. (2,3,
6–8,11,13,15,17,19,20,23–27). Practitioners are well served to
choose exercises with a low risk-to-reward ratio, regardless of
the health/injury status of the client or patient. Thus, there is
nothing to lose by adding the alternative exercises suggested in
Figure 9. Bird dog.
this article to an exercise selection library and using them with
both healthy and deconditioned populations.
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Volume 21 | Number 6
www.acsm-healthfitness.org
Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
25
EVIDENCE-BASED ALTERNATIVE EXERCISES
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Disclosure: The authors declare no conflict of interest and do not have any
financial disclosures.
D. Michael (Mike) Jett, Jr., M.S., C.S.C.S., EP-C, PN,
earned a B.A. in history (2000) and an M.S. in exercise physiology (2004) from the University of Louisville. He is currently a full-time instructor at the
University of Louisville in the Health and Sport Science
Department. He is an NSCA Certified Strength and
Conditioning Specialist, is an ACSM Certified Exercise
Physiologist, and has the Level 1 Precision Nutrition
26
ACSM’s Health & Fitness Journal ®
certification. He has more than 10 years of personal and group fitness
training experience.
Jessica Gibb, M.S., EP-C, CEP, FMSC, earned a B.S.
in exercise physiology (2008) from Ohio University
and an M.S. in exercise physiology with a concentration
in strength and conditioning (2011) from the University
of Louisville. She is currently a full-time instructor at the
University of Louisville in the Health and Sport Sciences
Department. She is a Certified Exercise Physiologist
and Certified Clinical Exercise Physiologist through
ACSM and has a Level 1 Functional Movement Screen certification. She
has 10 years of personal and group fitness training experience.
Dave Verrill, M.S., RCEP, CES, PD, FAACVPR,
earned his B.S. in physical education (1979) from
the University of Maine and his M.S. in exercise physiology (1982) from the University of South Carolina.
He is currently a full-time instructor and laboratory
director at the University of North Carolina at
Charlotte in the Department of Kinesiology. He is an
ACSM Certified Registered Clinical Exercise Physiologist,
Clinical Exercise Specialist, and Preventive & Rehabilitative Exercise
Program Director. He also is past president of the North Carolina
Cardiopulmonary Rehabilitation Association (NCCRA) and the ACSM
Clinical Exercise Physiology Association (CEPA). He has more than
35 years of experience in exercise testing, training, and prescription for
apparently healthy, high-risk, and clinical populations.
November/December 2017
Copyright © 2017 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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