Don’t Worry About Lifting Technique The importance of “lift with your legs, not your back” to prevent back pain has been exaggerated

The conventional wisdom is that we must not stoop to lift heavy objects. To avoid injury, we should squat down and then lift with our legs, not our backs. About 75% of physical therapists believe this,1 and the number is probably even higher outside that profession. It’s just as common for professionals to blame awkward and uneven lifting of lesser loads, as in this perfect example from a reader:

Every doctor and chiropractor and physiotherapist I have seen for months has told me that I have back pain because I’m carrying around my baby son. I don’t buy it! I had the same back pain for years before he was born. I don’t understand why they can’t understand that logic. It comes and it goes and I just don’t know why, but it isn’t my son, or it’s not just my son.

Her logic was solid: if the pain pre-dated motherhood, then baby-toting is a daft explanation for it.

All those pros who believe in the importance of good lifting technique probably wrong. In this section, I argue that it’s not just incorrect, but actually counter-productive. The truth is undoubtedly in the middle, but decades ago the pendulum of public opinion and “common sense” swung all the way to one side and got stuck there; I think it needs a firm (evidence-based) push back towards the centre.

For a more thorough and technical review of both sides of this topic, see Greg Lehman’s excellent review, “Revisiting the spinal flexion debate: prepare for doubt.” This article focusses just on making the case that the conventional wisdom is a myth: stooping to lift is not a significant risk factor for back pain, and most people don’t need to be taught how to lift simple heavy objects “properly.” Several sub-topics are not covered here, especially the athletic extremes (like powerlifting), special occupational challenges (like nursing or piano moving), or lifting during rehab.

The risks of poor lifting technique have been exaggerated.

Your back isn’t fragile and you already know how to lift things

Many activities are not nearly as dangerous as they seem. Being a Cirque du Soleil acrobats, for instance, is surprisingly safe, with an injury rate “lower than for many National Collegiate Athletic Association sports.”2

Intuition often fails us in musculoskeletal and sports medicine. One of the best important examples is that the bark of back pain is usually much worse than its bite and has surprisingly little to do with structural problems in spines like degeneration and injuries like “slipped” discs, muscle strains, pinched nerves, and so on. Although these things do happen, they are not as common or inevitably painful as most people imagine.3 Back pain is complex. Whether we get back pain is influenced by many non-obvious factors.

Although lifting in an awkward posture seems to be a major risk factor for back pain, that risk declines impressively with age (see Steffens). The older someone is, the less likely they are to trigger back pain this way. Are older people just a lot smarter (or more paranoid) about avoiding awkward postures? Once burned, twice shy?

Although we can’t lift heavy things just any old way, we don’t really need to be taught either, or just can’t be.4 What matters most is so obvious that it’s hard to get wrong: mostly just keep objects close to the body and balanced, and avoid lifting in awkward postures or when fatigued. These things are probably as risky as they are obvious. Lifting with an awkward posture specifically is a particularly impressive risk factor: a thousand people carefully quizzed about what they were doing before an attack of back pain were almost eight times likelier to have been lifting something heavy with an awkward posture.5

But simply stooping is not an “awkward posture.” As long as we cover those fairly obvious safety bases, there’s not much we can do to improve on it, and in particular neither stooping nor squatting has an obvious safety advantage over the other (the science coming below).

Although some of this still sounds a bit contrarian and radical today, the value of trying to tinker with people’s lifting habits to has been under fire for a long time. In 1997, Dr. Nortin Hadler wrote a paper for the journal Spine with the subtitle: “what you lift or how you lift matters far less than whether you lift or when.”6 In 2002, physical therapist Leon Straker wrote:7

Little evidence supports the effectiveness of training programs to change workers’ lifting habits and any attempt at change may just increase risk as workers lose the protection of well practiced and conditioned movement patterns.

That opinion was backed by a 2008 review of several years worth of evidence about lifting technique and low back pain:8

There is no evidence to support use of advice or training in working techniques … for preventing back pain or consequent disability. The findings challenge current widespread practice of advising workers on correct lifting technique.

(I’ll review some more specific and recent evidence below.)

I suspect training people to lift “properly” probably doesn’t work because backs are actually tough as good boots, and what makes backs hurt (or get injured) isn’t influenced all that much — if at all — by lifting technique, as long as you aren’t being really foolish about it. The conventional wisdom is based on an assumption of a fragility that just doesn’t exist in the back, so it’s not too surprising that the training doesn’t make much difference: there’s no vulnerability to avoid.

And that’s not the only bogus assumption in this mess.

Does heavy lifting actually increase the risk of back pain?

If lifting heavy things at work leads to back pain, then it would make more sense to be careful about how you do it. If.

As much as I appreciate their conclusions, Martimo et al. begin their paper with a whopper of another unjustified assumption, in the first sentence: “Heavy lifting at work increases the risk of back pain.”

If that assumption isn’t correct, the entire discussion is a moot point, right? And yet the authors support it with only a single reference to a 1999 paper published in an obscure journal, International Journal of Industrial Ergonomics 9 … and that paper supports nothing of the kind. It does not show that “heavy lifting increases the risk of back pain.”10 It’s a bogus citation! I am not making this up.

But that’s now ancient data in any case. Much more recently, a 2010 review concluded it’s “unlikely” that lifting was a cause of back pain in workers.11 A 2012 review found little to no evidence for any connection between back pain stooping over repeatedly or for long periods12 — a different angle on the same problem. Not enough reviews for you? Okay: a 2011 review of eight reviews “did not support” the conventional wisdom either.13

Never mind the weight: how about just the amount of time spent bending over? The stoopage factor? A 2015 study of 198 workers not only failed to find a link between the amount of back flexion and higher pain intensity, they found the opposite: more time spent flexing beyond 30˚ was linked to lower back pain intensity!14

None of this means that no one will ever hurt their back lifting something at work, but obviously the connection is nowhere near as obvious as everyone assumes. (Even the experts assumed it until quite recent history.) Likely there are major X factors.15

There’s no real smoke around lifting, so there’s probably no back pain fire.

Does stooping even put more load on the spine?

It is almost impossible not to flex your spine when lifting something off the ground, and there is remarkably little difference between spinal loading in different lifting techniques. Kingma et al measured 40˚ of spinal flexion even in a pure squat lift,16 the theoretical ideal lifting technique as understood by most people. Meanwhile, the lumbar spine flexed only ten degrees more when lifting the same way.

Or what if we could measure spinal forces directly? Imagine a pressure meter implanted in your back, completely replacing one of your vertebrae. What would it tell you, if you stooped over to pick up an object instead of squatting down to lift with your legs instead of your back? The nearly universal assumption is that stooping puts much more strain on the spine.

But if that was a safe assumption, I wouldn’t be bringing it up here. Just as Kingma et al found, there’s not much difference.

Those meters are actually a thing! Instrumented vertebral body replacements (VBRs) are high-tech gadgets installed in place of a vertebrae. Very cyborg! (Stronger, faster, more … measured?) In a 2016 experiment,17 three patients with VBRs did a bunch of lifting, and their implants measured the forces in squats versus stoops.

The difference was negligible! Squatting is the supposedly “correct” and safe way to lift, but it caused only 4% less load on tissues. That’s even less difference that Kingma et al found measuring flexion:

The current in vivo biomechanical study does not provide evidence that spinal loads differ substantially between stoop and squat lifting.

This is not perfect evidence, or the only evidence, but it’s enough to cast a lot of doubt on the value of advice to “lift with your legs, not your back.” And that’s all we need to make the case that the importance of lifting technique has been exaggerated.

What about back braces and support belts?

No one lifts more than bodybuilders and powerlifters. And bodybuilders must wear those big thick belts for some reason!18 If it makes sense for them, it must make sense for occupational lifting too. Surely.

Unless it doesn’t make sense for them. Siewe et al found that the use of weight belts increased the injury rate of the lumbar spine in powerlifters.19 Ruh roh!

And major recent reviews of the science have shown that there’s little or no prevention benefit to such belts in the workplace.2021 •sad trombone•

Interestingly, even hard braces are amazingly ineffective at reducing the forces on the spine!22 See Spinal Fracture Bracing: My wife’s terrible accident, and a whirlwind tour of the science and biomechanics of her spine brace — fascinating topic.

Supports, braces, and belts mostly just provide some novel sensory input that reinforces the idea of security and stability — a sensation-aided placebo. That is, you don’t just hope that it supports your back, it feels like it does. Unfortunately, this also strongly encourages the insidious idea that backs need stabilizing in the first place. And that’s how you lose The Mind Game in Low Back Pain.

Safe lifting technique? That’s a lot of stoop, with a lot of weight! Photo by U.S. Naval Forces Central Command/U.S. Fifth Fleet

Another lesson from powerlifting

Deadlifts do not remotely look like a “safe” way to lift something heavy with your back. And yet the sport of powerlifting demonstrates that it’s possible to do deadlifts regularly without any obvious pattern of vulnerability to back pain. These guys and gals are stooping over and picking up dramatically more weight than anyone is ever going to lift at work.23 For fun. With, science says, less injury than other sports!24

Most powerlifters try to minimize spinal flexion, especially lumbar flexion, but it’s not clear that many of them are actually succeeding … and for sure many amateurs definitely fail, either because of poor training and/or because it is biomechanically difficult to achieve. Remember, it is nearly impossible not to flex your spine when lifting something off the ground.25 And so most deadlifts and strongman lifts bear a striking resemblance to how people are not supposed to lift, and yet the sport is amazingly safe.

But this isn’t about powerlifting: I’m just using powerlifting as an example to make a point about saner loads. I am definitely not saying that it’s safe for an untrained person to try to lift huge loads willy nilly — technique does matter when you’re trying to get several hundred pounds off the ground! It’s a completely different thing than schlepping stuff around in a warehouse. I am only saying that the range of what it’s possible to do surprisingly safely is just huge. If backs were actually prone to injuries when lifting 20-40 kilos with poor technique or training, it’s unlikely that people could ever safely multiply that by 3-10 times in deadlifts, but they clearly do, even with imperfect elimination of flexion, if that is even possible.

The point is that backs are naturally sturdy and non-fragile, and powerlifting is a great demonstration of that.

Don’t worry about how you lift … but don’t be a fool either!

Obviously you can hurt yourself if you are reckless with heavy loads. And obviously technique does matter for extreme loads (the kind of loads no one would ever be expected to deal with at work). Strain hard enough and you will get a muscle strain (a tear), or worse. And although disc herniations may be less common and less serious and less related to either lifting or back pain than people think, that doesn’t mean you want one.

But training for lifting technique is probably not important because heavy lifting itself probably does not actually increase the risk of back pain significantly in the first place — and so there’s no problem to solve with better technique, and no evidence that there is even any way to significantly improve on our technique. Doubtless heavy lifting is at least a little bit of a factor in back pain, just not a major one — not the kind of factor that generates a nice clear statistical signal.

Back pain that starts with a lifting trauma probably occurs less than most people think, and isn’t as severe, and when it does occur it probably often seems worse than it is due to the common problem of trigger points in back pain.

About Paul Ingraham I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter.

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