This article is the first of several I am writing on traditional strength & conditioning movements and how they can be used both traditionally as well as in the physical therapy setting.

Using the Deadlift as a Rehabilitative and Post-Rehab Global Strength & Conditioning Movement for all Populations

Joshua Slone, NSCA-CPT, B.A., ACSM-EIM 1, MFN-P

Introduction

The deadlift is an often bastardized and feared weightlifting movement, and for good reason. Lifters who are unprepared technically or in terms of maximal strength for this movement will find the lift difficult and perhaps pain provoking, and coaches who do not know how to instruct the movement or perform it themselves with competency will also have apprehension towards the movement. It does not have to be this way.

Most people “incorrectly” deadlift because they lack the proper instruction in the fundamentals of the hip hinge, intra-abdominal pressurization (IAP) and spinal bracing, and they lack the neuromuscular coordination (which manifests as proper form) to execute the movement efficiently and safely.

Furthermore, trainers and physical therapists alike should not eschew this movement and its variations because of a preexisting injury, lack of confidence in the patient or client, or a dislike for the movement. The only reason a trainer or provider should not use the deadlift is if either professional is not competent in the movement themselves. This is the primary prerequisite the coach must meet to coach a deadlift-pattern movement. Another prerequisite is a thorough understanding of joint function, which all trainers, coaches, and physical therapists should already be competent with. Finally, the instructor must know how to modify the exercise appropriately for the given patient or client. A “one size fits all” approach does not work and puts the patient or client at risk, for which YOU ARE LIABLE!

The mindset that a deadlift must start on the ground and involve “full range of motion” is also a flawed one. There are various styles of pulls, such as conventional and sumo stances, and each lifter will have ankle, knee, and hip joint angles through the movement that are unique to them, their structural anatomy, and their current state of physical conditioning and mobility. A client who lacks the hamstring flexibility to start with the bar below the knees can begin with a rack pull or a block pull above knee height. This is actually a very good way to begin coaching the hip hinge that is the cornerstone of the movement, as progression can simply be accomplished by lowering the starting point of the lift one notch on the rack at a time, until a comfortable “final depth” is established for the client.

But what about those with knee, hip, and back injuries? Simple. Conduct full ROM assessment to find pain-free ROM, started unloaded with a PVC pipe or similar light weight training bar to coach the mechanics of the movement slowly; use dead bugs and similar drills to coach IAP and bracing, and a progressively deeper RDL to develop mobility and strength in the hamstrings and glutes.

For clients who need significant strength development prior to beginning deadlifts, use farmers walks, loaded both bilaterally and unilaterally as well as unevenly, to practice bracing under load and locomotion. Including step ups and step downs in these drills can be beneficial as well. For lower body initial strength development, machines can be used but typically, traditional multi-joint movements will be preferable, provided the client is able to perform them properly.

The two movements that will primarily help reinforce proper lifting mechanics (form) as well as promote mobility and strength are the rack pull and Romanian deadlift (RDL). The rack pull is concentric-only, just like a regular deadlift from the ground, and is used to focus on hip extension and controlling lumbar and thoracic extension (avoiding the common “chin/chest up” pitfall that often results in T-spine extension and L-spine extension). The RDL is a top-down eccentric-concentric movement, and the client will build pulling depth by slowly progressing the depth of the eccentric phase. This movement can also be performed unilaterally either as a test of symmetrical strength and coordination, or as a strength and hypertrophy movement. I advise that the client develop a measure of proficiency with the bilateral deadlift before progressing to unilateral variations, as these require substantially more strength, balance, and coordination to perform safely.

Both movements can be performed by virtually any client of any age or population, provided the coach appropriately scales intensity, technical difficulty, and volume of the movement. The notion that a little old lady cannot deadlift is one borne of small minds that are afraid to push boundaries. There are MANY geriatrics that are stronger than then they were as young adults, and some are even competitive strength athletes today and are setting world records!

Benefits of the Deadlift

From an ADL (Activities of Daily Living) point of view, the deadlift is MASSIVELY functional! We all bend, stoop, squat, or hinge over to pick up things off the ground, move items across floors, and we wrangle children and pets in these “compromised” positions. Logically then, training should reflect common ADL movements and seek to improve strength through all pain-free ROM so that when the body is in a compromised position (such as bending over to pick up the newspaper) the muscles and all their connective tissues are RESILIENT enough to manage the workload without succumbing to fatigue and fiber failure (tissue damage).

With respect to bone health, and the conditions of osteoporosis and osteopenia, the deadlift is FANTASTIC at providing the heavy, axial compressive loading our bones need to stimulate osteogenesis, or the formation of new bone cells. Without external loads on the body, our bones do not increase and maintain their density and strength. An example of this can be found in astronauts, who go without the compressive forces of gravity for months at a time in space, and when they return, they have lower bone mineral density and lower bone mass as well. There are NO “physical therapy movements” that provide substantial axial loading and compressive forces to trigger osteogenesis. While some loading is better than none, it takes simple, conventional training movements to spur and elicit the desired adaptations in the human body. This is not up for discussion; this is a basic fact of human physiology.

How about burning Calories? A deadlift will do more for metabolic stress than isolation movements, such as hamstring curls or leg extensions due to the much larger masses of muscle recruited for the movement. Hamstrings, glutes, and spinal erectors do the majority of the hard work (with the erectors contributing mostly isometric tension to brace the spine); the core musculature to include RA, TVA, Int/Ext Obliques, and QL all engage isometrically to brace the spine; the feet are actively “grabbing” the floor, the lats, rhomboids, rear deltoids, and entire trapezius contribute isometrically to stabilize the upper back and T-spine and to keep the bar close to the body as it is pulled upwards. So, we can quickly see that we get MASSIVE motor unit recruitment and that coordination of all these muscle actions is required to execute the lift properly.

The strength gains from the deadlift are obvious, and do not require much elaboration. Power gains, on the other hand, are significant and worth noting, as this can have sports-specific or job-specific carryover into daily life. Lower body muscular power is also an indicator of how easy certain ADLs will be, such as ascending tall stairs or hiking uphill.

As the client progresses with their deadlifts, some gains in work capacity/strength-endurance will be achieved, mostly with carryover to sub-maximal activities such as carrying groceries in one or both hands, carrying children, or objects in the workplace. This is especially important in the aging population as tendons and ligaments degrade over time due to age and use, and the deadlift, along with other strength movements, can repair and reinforce these connective tissues, thus reducing injury risk.

Prepatory Movements for the Deadlift

Now that the benefits of the movement have been established, we can now discuss coaching of the movement, starting with two supplementary movements that have technical applicability to the standard deadlift.

Beginning with a “healthy” client, who passes pain and ROM testing without restriction or issue, start with the RDL and an unloaded barbell. The standard 45lbs/20kg bar is light enough for most clients to handle and provides enough load for the client to “feel” what is going on during the movement. You can also use a PVC pipe or something similar if you feel that the client needs zero loading while learning the movement initially, but an empty barbell should be appropriate in the majority of cases.

Romanian Deadlift:

1. Set the client up in the rack with the barbell about hand-height when the arm is along the side of the body.
2. Instruct the client to start the movement at the hips, pushing them back as if they are going to bump a car door shut.
3. Instruct the client to bend the knees slightly, just enough to permit the bar to slide down along the front of the thighs, and if they have the mobility and strength, past the knees to mid-shin. The hips should be pushing backwards, bringing the joint into flexion, and closing the angle.
4. The client in the bottom position should have a relatively flat back (relative to their natural posture), an acute hip angle, obtuse knee angle, and a nearly vertical shin (if the shin is not vertical, there is too much knee flexion occurring and not enough hip flexion). Instruct the client to keep their chin in a neutral or slightly tucked position to avoid spinal extension.
5. The concentric portion of the lift begins with the client squeezing the glutes and hamstrings to pull themselves into the same erect but braced position (they should not be standing perfectly straight up at the top of the movement). Cue the client to push their hips through the bar, “pinch a penny,” or similar cues to elicit the desired movement. Also cue the client to forcefully exhale as they ascend.
6. The knees will straighten after the bar has moved superior to the knee joint.
7. The client returns to the starting position, chin neutral, shoulders retracted (not excessively), pelvis squarely under the shoulders and rest of the torso. This is also when they inhale, preparing their abdominal brace for the next repetition.
8. The client repeats the movement for repetitions following the same steps as above for each repetition.

The rack pull is a concentric-only movement, just like the deadlift from the floor, and can be overloaded more (relative to a pull from the floor) to increase hip extension strength and lockout ability.

                Rack Pull:

1. Set the client up in the rack with the bar set at just above or just below the knee. If the client cannot get into a good starting position at a lower setting, start with a higher setting.
2. Instruct the client to brace their core, maintain a relatively flat back, and push through the bar with their hips. They should have tension in the hamstrings and glutes in the starting position, and they should exhale forcefully as they exert themselves to lift the bar up.
3. The client’s chin should be tucked or neutral to reduce the chance of spinal extension during the movement.
4. The upper back musculature should have similar tension to the RDL, keeping the bar tight against the body as it ascends.
5. The movement is finished when the client reaches the upright position while maintaining their core brace. The hips should be squarely under the torso and shoulders, rib cage should be drawn down and not flared, and the chin should be neutral at the top of the movement.
6. The client should lower the bar under control quickly to the rack. Towels or pads can be placed on the safety bars in the rack to reduce the noise from putting the bar back down.
7. The client should reset for the next repetition, setting up just as they did in steps 1 and 2.  

These two movements provide the foundation for the deadlift. Hip extension, hamstring mobility, glute engagement, core bracing, grip strength, terminal knee extension…all are trained in these two movements.

Instructing the deadlift itself is nearly identical to the rack pull, as both are concentric-only hinge movements that use the posterior kinetic chain.

                Deadlift:

1. Set the client up in the rack or on the platform in the lifting stance that is most comfortable for them. This is where they select either conventional, sumo, or a mixed stance that is in between the two. Knees should track straight over the feet as the knee flexes in the bottom of the movement. This is how you determine the angle at which the feet should be externally rotated.
2. If the client does not have the mobility to pull from the floor, use pulling blocks, heavy pads, or supports in a power rack to place the lifter at the appropriate pulling depth.
3. The client should have the bar centered over the middle of their feet as they set up.
4. The client can set up their core brace either prior to grabbing the bar or afterwards. What matters is that the client can maintain a relatively flat back and core pressure during the lift. The chin should stay tucked or neutral to avoid spinal extension propensity.
5. Ideally, double overhand, “hook grip,” should be used as this is safer for the bicep tendons than mixed grip, but if the client’s hands are not large enough for hook grip or they lack the strength and calluses, direct them to use a mixed grip with the dominant arm being supinated and the off-hand pronated. It would also be advisable to program bicep curls with full ROM (to include the minor shoulder flexion the bicep is responsible for), to promote strength and resiliency of the bicep tendons.
6. In the starting position, the client should have a strong brace, belly full of air, and massive tension built up in the back and lower body. Cue the lifter to tense their lats and pull the bar into them and to take the slack out of the bar prior to executing the lift.
7. The lift begins with simultaneous hip and knee extension, with the former being dominant. Cue the client to push their hips through the bar and to bring their hips “under their shoulders.” Avoid cues such as “head up” or “chest up/out,” as these can inadvertently result in thoracic or lumbar extension, thus breaking or weakening the core brace. The client should be forcefully exhaling during the entire concentric phase of the movement, as this will help to further pressurize the core and stabilize the spine, and result in greater power output.
8. The lift is complete when the lifter is standing in an upright position with hips, knees, and ankles in fully extended positions, and the pelvis tucked squarely under the shoulders, maintaining a proper core brace.
9. The lifter can then breathe, lower the bar under control, fully reset at the bottom, and lift for repetitions if that is what is programmed. Ideally, the bar should come to a complete rest on the ground prior to another repetition. “Touch and Go” repetitions are not recommended for most lifters as they require a very high degree of technical proficiency, sustained power output, and a continuous (and often exhausting) core brace.

Programming the Deadlift as a Global S&C Exercise

Now that we have explored how to coach the deadlift for healthy lifters, we can now discuss programming the deadlift for such purposes. Since the deadlift is a strength and power developing movement, we will want to use a set and repetition scheme that emphasizes these attributes.

Maximal strength is developed in the 1-5 repetition range with high (75%+ maximal load, RPE of 7+) with long rest periods between sets and usually 3-5 sets to provide for the accumulation of volume without negatively impacting per-repetition strength and power expression. An example would be 4 sets, 3-5 repetitions per set, with a 3-4-minute rest period between sets. The reason the rest periods are several minutes long is to permit full clearance of Central Fatigue (CNS fatigue) as well as metabolic fatigue from the body.

Power is best developed using moderately light to moderate loading, with a moderate repetition range (4-8), with multiple sets and long rest periods. In example, 5 sets of 4-8 repetitions, 50% 1RM loading, 3-minute rest periods. The difference between deadlifting for strength and power is that with strength, it does not matter as much how long each rep takes, so long as it is completed. For power, maximum velocity per repetition is the goal, and you can reduce the loading over the course of the sets to maintain consistent bar speed. The rest periods use the same logic as for strength.

Guidelines for Programming the Deadlift for Strength:

1. Start low and slow, build movement proficiency before heavy loading. If they cannot perform the deadlift for reps with light to moderate loading with proper form over the course of 3-4 weeks, do NOT increase the loading!
2. Start with 2-3 sets, 2-5 repetitions, with 3-4 minutes between sets (autoregulate this based on the client’s conditioning as they progress)
3. Keep the loading moderate (RPE 5-6, 50-65% 1RM) until they have built confidence and strength with those loads.
4. Progressively overload and periodize the loading until the client reaches maximal loading (90+% 1RM), deload for 1-2 weeks using roughly 40% 1RM/RPE 4-5, and then resume at 55-65%/RPE 5-7) after the deload period. Deloads should be conducted every 3-6 weeks and will depend on your client’s state of conditioning and ability.

Guidelines for Programming the Deadlift for Power:

1. Start low and slow with respect to loading and speed, build movement proficiency and consistency before emphasizing the speed of the bar.
2. Use loads in the 40-55% 1RM/4-6 RPE range. These are sufficiently heavy enough to spur neuromuscular adaptations such as rate coding, which contribute to increased power output.
3. Start with 2-3 sets of 4-8 repetitions. Use cues appropriate to the client to elicit maximum speed while also maintaining core brace and overall form. The lifter might be tempted to extend at the mid back, raising the chin and chest to “get the bar up faster.” Kindly discourage this and encourage a neutral chin position
4. Progressively overload and periodize the movement increasing the loading through the 40-55% 1RM/4-6 RPE range, and coaching the client to hit the top of the repetition range before advancing loading (i.e., the client should be doing 3 sets of 8 reps with consistent bar speed at 45% 1RM loading before advancing to 50% or higher loading).

The deadlift should not be used as a training movement for hypertrophy, as volume and mechanical tension are the primary drives of this adaptation and the deadlift is a highly taxing movement, thus preventing the accumulation of quality volume of repetitions. Similarly, the deadlift is not ideal for muscular endurance training, though some endurance (primarily grip) will benefit from the deadlift.

Use of the Deadlift in a Rehabilitative Context

                The deadlift can be used as a rehabilitative exercise for patients with knee, hip, and back injuries, provided that the movement is appropriately modified for the patient’s unique needs and current capabilities. Bilateral variations may be appropriate for some, whereas unilateral variations will be more beneficial for other patients. It is up to you as the provider to determine which variation is ideal for the stage of therapy the patient is currently undergoing.

                A full ROM assessment is required first to determine pain-free ROM as well as the degree of pain and tolerance of pain. Pain beyond a 2 on the 1-10 scale should be addressed first, as well as any trigger points, and initially in therapy the deadlift may not be an appropriate training tool. For the sake of this discussion, we will presume that the patient has at least enough pain-free ROM and inherent strength to perform a rack pull at approximately mid-thigh level.

                The coaching for the deadlift, rack pull, and RDL in the rehab context is nearly identical to that for a healthy patient or client. As the provider, you will already know the restrictions your patient has, their progress in therapy to date, as well as a general understanding of the state of their self-efficacy and self-confidence.

                Selection of which deadlift variation to use with your patient will depend on their specific injury, rehab state and progress, and inherent strength and neuromuscular coordination. The rack pull and RDL are recommended as a starting point for all patients, prior to coaching the deadlift from the floor.

                Now, some patients will never progress to pulling from the floor for one reason or another, and this is fine. So long as the patient has learned and manifests proper form (core brace, hip hinge, neutral spine relative to normal posture) in the variations you have taught them, you have done your job as a coach with regard to the movement.

                Programming the Deadlift and its Variations for the Rehab Patient:

1. Start low and slow within pain-free ROM. Progress ROM accordingly with the patient’s overall therapy progress. If the deadlift or a variation provokes pain, STOP. Investigate the source of the pain. Is it improper technique? Strength imbalance between anterior and posterior chains? Asymmetrical strength imbalance?
2. “Where they’re tight, get them mobile. Where they’re weak, get them strong.” “Balance strength around each joint.” If this means you delay using the deadlift until isolation movements have produced the desired and needed strength and coordination adaptations, then so be it. Safe progression is one of the underlying goals of physical therapy.
3. Start with 1-2 sets (preferably 2 if tolerable) of 3-5 repetitions each. Provide sufficient rest time between sets to permit central and metabolic fatigue to clear. Weekly frequency should be 1-2 times per week and will depend on how many times a week you see a given patient, as well as the patient’s tolerance for exercise training.
4. COACH the patient on how the deadlift relates to ADLs and will help them become globally strong and capable as well as improve their therapy outcomes. Psychosocial support to the patient is critical for physical therapy to be efficacious. INSTILL a healthy sense of confidence and ego within the patient. They CAN lift! They CAN Move Well and Live Well!
5. Deloading will likely not take place during physical therapy since patient’s visits and duration are limited by health insurance in many cases. Just ensure the client progresses safely and effectively during their time with you. If the patient stays with you for several months, you can progress, deload, and progress using flexible linear periodization according to the patient’s progress.

A final note for the rehabilitative context: physical therapists, please refer your patients out to qualified Health & Wellness Coaches and movement professionals (such as a medical fitness specialist) once your patients are close to the end of their physical therapy regimen, or even right at the start! The HWC can assist them in making positive lifestyle changes (and can even be done concurrently with physical therapy) and the movement professional will take them at the end of therapy and continue to build their global strength & conditioning, thus improving short and long term patient outcome measures. The issue of non-compliance with Home Exercise Programs (HEPs) is common knowledge in the physical therapy domain, and an HWC or other qualified movement professional can assist with ensuring adherence to care orders.

Final Thoughts

            For all its benefits, the deadlift is not the “end all, be all” for rehab and global S&C. It has times where it is applicable, and there are others where it is not. It is up to you, the provider and coach, to determine whether a deadlift variation is needed or beneficial, and how to integrate that into your client or patient’s program.

                If you do not know how to deadlift, or you are not confident with your deadlift and variations, LEARN! The Kabuki Movement System video tutorials are free on YouTube, and provide fantastic, evidence-based, high quality instruction in the deadlift as well as the bench press and back squat. Squat University is another fantastic evidence-based resource for the major lifts, including Olympic lifts. You can also hire or coordinate with a colleague who is competent in the deadlift to teach and train you. Either way, expand your toolbox and skillset. You, your clients, and patients will benefit.

                If you’re one of the few who passionately despise the deadlift and believe it to be useless or needlessly “dangerous,” and perhaps that mindset is because you or someone you know was injured during a deadlift, get a coach and learn. Mastery of the hip hinge and all associated movements is expected of a personal trainer, S&C coach, and physical therapist. Take the time to educate yourself, expand your mindset, and perhaps your view on the deadlift will change.

                Finally, remember that the deadlift is only one of myriad ways we can learn to Move Well and Live Well!

Serving Through Strength,

Josh