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Discovering Strength: An Orthopedic Surgeon’s Perspective

by Frederick J. Barnes MD FAAOS FACS | June 26, 2019

starting strength event

In the United States, over 300,000 people will fracture their hip in the upcoming year. [1] This is a devastating injury, usually occurring in people over the age of 65 with brittle bones from osteoporosis. Three-quarters of those suffering hip fractures are female.  After fracturing a hip, almost 50% will need to use assistive devices while ambulating and approximately 20% sustaining the fracture will die within a year.

I am a practicing orthopedic surgeon with over 30 years of clinical experience. I have treated thousands of patients with fractures.  I have encountered too many frail elderly patients with hip fractures. My job has been to help patients after their injury.  But what if I shifted focus and spent more of my time educating patients on the benefits of strength acquisition and its relationship to fracture prevention?

As people age, they become more sedentary, and concomitant muscular atrophy results in a loss of strength and power. Essentially, they become brittle and weaker. Their own homes become actual danger zones with obstacle courses and booby traps, where a momentary misstep can lead to life-changing consequences.  The combination of sarcopenia, dynapenia, osteopenia, and frailty seem to be the reward for living past middle age. But it doesn’t have to be this way.

I have heard a repeated story: they slipped while getting out of the tub, tripped on an electric cord, stumbled over a carpet, or got up too fast and fell. The stories were all similar. Most of the falls were low-energy, from waist height or less, resulting in fractures of the hip, wrist, shoulder, or spine. I remember hearing older physicians say, “We are born through the pelvis, and leave through the hip.” When you consider that the one-year mortality rate for hip fractures is between 10%-30%, that saying was not far off.

We have all known friends or family members who have sustained these fractures. The effects on the patient’s spouse and family are profound as well. The proximate cause of the fracture is usually the fall – the surrounding variables are more complex. Elderly patients tend to have multiple comorbidities and frailty.  Orthopedic surgery tends to be reactive, not proactive. We fix the fracture, not the situation that caused it.

Unfortunately, even after the appropriate surgery many people require continued use of crutches, walkers, or canes. Some have a decrease in their ambulatory ability. If they were independent “community” ambulators, sometimes they regress to household ambulators. Some patients never regain their ability to walk independently. There must be a way to prevent at least some of these injuries.

Enter the Barbell Prescription   

During an online search for recommendations for middle-age fitness, I came across The Barbell Prescription: Strength Training for Life After 40. Up to that point I had never heard of Starting Strength. I understood the benefits of weight lifting on bone density, but never really acted upon it. When I looked into the book I noted that the author was a physician and scientist. I purchased a copy from Amazon, and looked forward to hearing what the writer had to say.

Reading that book has changed my life. It awakened a passion in me. I want to help my patients get stronger. By doing so, maybe some of those debilitating fractures could be prevented. Dr. Sullivan’s groundbreaking work The Barbell Prescription lays it all out plainly.  His description of the Sick Aging Phenotype (SAP) which includes the Metabolic Syndrome, Sarcopenia, Osteopenia, Frailty, and Polypharmacy is very eye-opening. He develops a strong case for structural strength training, and a road map to attack the SAP. He has the rare ability to take a very complex subject and simplify it, while giving the reader the important salient information without inundating with minutiae.

After reading the book, I actually felt propelled to get off my butt and do something about strength and fracture prevention in the elderly. I wanted to help my patients. I wanted to spread the word about the importance of strength training.  I also understood that you need to lead from the front. I couldn’t simply talk about strength training with my patients, I had to have some skin in the game.

Barbell Training

Before encountering the Barbell Prescription, I was a typical exerciser. I get up most mornings around 4:30 am. I would climb up on my elliptical and exercise for 30 minutes getting in my “cardio” for the day. A few times a week, I would visit the local big-box gym, use their cardio and weight machines, do an occasional dumbbell curl and come home sweating.  There were no structural movements in my exercise routine. There was just more elliptical training, machine-sitting knee extensions, prone hamstring curls and maybe an occasional standing upright row. Most have heard this story before.

After reading The Barbell Prescription I reconfigured my exercise schedule. I was intrigued by Dr. Sullivan’s description of bioenergetics. I wish he had taught my medical school class on this topic. I learned that when performing mostly endurance exercises favoring the small slow-twitch muscle fibers, I was not targeting strength and power. The structural compound barbell lifts with their muscle stimulating effects promoting type-II muscle fibers made so much more sense.  I had been performing the low slow distance endurance exercises and not getting any stronger. I needed to effect a change.

Starting Strength: Basic Barbell Training 3rd edition

The Barbell Prescription refers the reader to Starting Strength for comprehensive instruction pertaining to the performance of the big compound structural lifts. I decided to follow the method. I now had formulated a plan and had a compass heading to follow.

I bought myself copies of both the Starting Strength and Practical Programming for Strength Training and devoured them. I wrote copious notes in the margins. Underlining key points in the text.  Each morning, I would read the books and when finished, reread them again. Feeling I was on to something I purchased additional copies of all 3 books and gave them out to my friends and colleagues. I wanted to ignite their interest as well. The facts are very convincing: being stronger is good for everyone. My plan was to begin working out in my basement, where I could begin to train away from distractions of the big-box gym.

Setting Up My Gym

On the advice gleaned from the Art of Manliness post on constructing a proper weightlifting platform, I headed to Lowe's. After purchasing the required 5 sheets of plywood, wood screws, and wood glue, I went to Tractor Supply and got some horse stall mats. I carefully constructed my platform, applying multiple coats of varnish on the centered hardwood veneer and was then ready to go. I can say that the act of lifting the sheets of plywood and the rubber horse stall mats gave me more of a strength workout than the other gym ever did. I bolted down my new power rack from Rogue, and bought a decent power bar and a few plates. I began training in earnest.

Backwards Approach

In retrospect, I believe my approach to Starting Strength was a little backwards, having read The Barbell Prescription first, followed by Starting Strength, and Practical Programming for Strength Training, I felt I just needed to get the word out to those willing to listen. In truth, I had never seriously thought of using barbells before. I was of the opinion that they could be really dangerous and could potentially cause back injuries. As an Orthopedic Surgeon, I had seen my share of young guys with screwed up shoulders blamed on barbells. It never occurred to me that they were possibly using poor technique or had uninformed coaching for the lifts.

I began my novice linear progression (NLP) in my basement, and then went looking for the first Starting Strength course I could find. I signed up for a squat coaching workshop at the Woodmere Fitness Club, a Starting Strength Affiliate Gym on Long Island. The fact that I had just started my NLP did not dissuade me from signing up. I reasoned that I had read the books and I knew a thing or two about musculoskeletal anatomy being an Orthopedist.  My coaching experience up to that point only involved coaching a few friends, which in retrospect was like teaching from book knowledge without any practical experience. 

I arrived at the Woodmere Fitness Club where I met SSCs Nick Delgadillo and Inna Koppel. They are great people, knowledgeable, experienced, and very professional. I loved it. I realized I had much to learn about barbell strength training and the model. I was welcomed. I was never made to feel out of place even though I was jumping the gun by beginning my coached barbell training by taking a coaching course. Common sense would dictate that I should be proficient in the squat before trying to coach it, right?  Like we used to say in surgical residency, with a mixture of feigned confidence and undeserved cockiness, “Not always sure, but never in doubt.” I was impressed by the caliber of my fellow students, all passionate in their pursuit of learning to be professional coaches. They were intelligent, highly motivated and pretty strong. The term “professional” is used a lot, maybe sometimes too much. It is appropriately used when describing the Starting Strength organization. Starting Strength is the real deal. I needed to experience more, and I was motivated to learn.

The Seminar

Shortly after attending the squat coaching camp, I signed up for the first Starting Strength Seminar I could get, changed my work schedule, and drove down from northeast Pennsylvania to Westminster Strength and Conditioning in Maryland. I arrived early, got to the gym and saw a familiar face, Nick Delgadillo SSC; he made me feel welcomed. I saw Mark Rippetoe and nodded hello. I recognized some of the staff coaches from videos on the Starting Strength website. I was very excited to be there.

The Starting Strength Seminar imparts a tremendous amount of information in a relatively short period of time. The material is presented in an organized and educational atmosphere conducive to learning. The staff coaches are all professionals to a person, and experts in their field. They teach from a detailed knowledge of the subject and a wealth of experience under the bar. My fellow seminar participants were engaged and interested. I was impressed with the seminar attendees' degree of preparedness for the course. Everyone I talked to had read the books, many had completed their NLP, and some were also engaged with online coaching.

They all came to learn the barbell lifts the right way, from the source. As a practicing physician, I have spent my share of time lecturing and teaching. I know and value the importance of imparting knowledge. With the proper focus, the attitudes of the instructors and students taken together tend to create synergy in learning. This was that kind of experience for me. My time on the platform was enlightening. I definitely had my work cut out for me. My fellow seminar participants were supportive. We helped each other, learned to coach one another and progressed through the Squat, Deadlift, Bench Press and Press. I had issues with rounding the low back, and was shown how to correct it, as well as the real importance of reaching proper depth and using hip drive out of the hole.

When it came to the Power Clean I had my reservations. I had never performed the Power Clean before, thinking that at 60 years of age I was probably past incorporating that movement into my training. I was wrong. When learning the Power Clean for the first time, Nick Delgadillo told the group to be careful because somebody will always drop the bar on their feet – yep, that was me. Somehow, I avoided any serious injury and kept on moving right along, only injuring my pride a little. Rip was great, and only mildly intimidating when it was my turn to demonstrate my Power Clean around the platforms. I think I was able to show that even though I had received excellent online instruction on the movement from Niki Sims, the Power Clean would be something I would have to practice at home before being ready for prime time. I have since added it to my training, and have made steady progress with the movement. I like the idea of demonstrating power, so I continue to practice doing so with the Power Clean.

To those contemplating attending a seminar, I can strongly recommend doing so without reservation.  I have already recommended the seminar to a few physician colleagues, the older, seasoned ones. They ask me what I have been doing – “You look different, a new diet?” No, I tell them, I am training, and they should too. I plan on returning to another seminar probably next year, hopefully bringing a few along with me. Maybe I will opt in for the platform coaching evaluation.

Getting the Word Out

So, at this point, I continue to work full-time as an orthopedic surgeon with office and hospital obligations. I continue to train the barbell lifts. I now as a matter of course talk about strength training to almost every single patient. I explain why they need to be lifting weights and the importance of keeping their bones strong. I have my older patients demonstrate their ability to sit up from a chair, and then I teach them how to use the strongest muscles in their bodies, even if they came in for me to check on their carpal tunnel. Everyone gets the talk about the importance – the real importance – of strength. I refer patients to the Greysteel YouTube channel and the Starting Strength website. I continue to recommend the books and urge them to start training. I am planning a community presentation at our hospital on the importance of strength in healthy aging and how to go about it. I have encouraged my Athletic Trainers to log on to the Starting Strength website and begin their journey. They have also been given copies of the 3 books. Their interest has been piqued. They get it.

Stronger You = Stronger Bones

The medical literature clearly points to resistance training (i.e. strength training) as a strong force to reduce osteoporotic fractures. [3] As detailed in The Barbell Prescription, strength training with barbells attacks the atrophies of aging by training muscle, strengthening skeletal structure, and helping balance and mobility in everyone, but especially the elderly. The skeleton responds to stress the same way other biologic systems do, through the stress of loading, recovery, and physiologic adaptation. Bone gets stronger because it must – it responds to the increasing tension and loading from strengthening muscle. Combining the increase in strength with improved bone density, exercise tolerance, and balance contributes to both fall prevention and survival, as well as enhanced well-being.

I have a few patients who are well into their nineties. One thing they have in common besides a positive outlook on life is that they have exercised their whole lives. One gentleman, a former C-47 pilot from World War II who flew and dropped paratroopers at Sicily, Normandy, and Market Garden, will be 100 on June 16, 2019. He has gone to the gym for as long as he can remember, and still goes independently 3 times per week. He is proud of his independence. He continues to lift weights. He recently asked me jokingly if I had any exercises for his eyes. Why? He has his driving test scheduled for June 17, the day after his birthday, and wants to train for that as well. He has a lifetime of experience with lifting, and he understands the benefits of training.

Strength for Life

As an expert in Musculoskeletal Medicine, I’ve spent the majority of my career repairing the injuries of those patients who have lost their strength due to aging and other infirmities. As I pass middle age myself, I understand that barbell strength training is important, and quite frankly very personal to me. I am biased towards action. I see the benefits of training, and I am getting stronger. Now the importance of strength is foremost in my thoughts. It has always been right out there, just in front of me, but I didn’t see it until now. So there is not a moment to lose – the clock keeps ticking. Go on and get stronger, and bring others along too.


References

  1. CDC-Centers for Disease Control and Prevention: Home and Recreational Safety-Hip Fractures Among Older Adults.
  2. The Barbell Prescription Strength Training for Life after 40, Jonathon M. Sullivan & Andy Baker  pp 5-16. 20163. Strength Training in the Elderly.
  3. BF Hurley, SM Roth-Sports Medicine 30(4) 249-268, 2000.

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