Here's how we know humans are antifragile:

• Yoga is pretty dang safe here
• But if you REALLY want a safe sport, take up breakdancing here (no, seriously!)
• Or Crossfit here
• Knees going in during a squat or lunge doesn't predict injury here
• Plus here are my TWO episodes looking at this topic here and here

But what DOES predict injury:

• Having weak hamstrings here
• Having a weak barbell squat here
• Doing too little for too long, followed by too much too soon here and here

And what protects against injury:

• Strength training is the best injury prevention here and here
• High consistent workloads protect against injury here

Mentioned in this episode:

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:: 00:06

Welcome to Pilates Elephants, I'm Raphael Bender. How do we keep our clients safe in Pilates?

:: 00:12

I'm going to have a reasonably in-depth tour of the literature on injury prevention,

:: 00:19

alignment and load and see where that takes us and,

:: 00:24

come up with some strong evidence-based recommendations on how you can run your Pilates classes to,

:: 00:33

keep your clients as safe as possible.

:: 00:36

All right, so the two big questions here that kind of really interlock quite

:: 00:41

a lot are to do with, firstly, alignment.

:: 00:46

So to what extent, if at all, does alignment predispose people to injuries?

:: 00:50

And I'm talking about alignment, not just within a particular move,

:: 00:55

so like whether your knee is pointing in or out when you squat,

:: 00:58

but also just the choice of moves, like is it safe to do backbends or rotations under load?

:: 01:06

And so that's the first area I want to explore, alignment and relationship to injury risk.

:: 01:11

And the reason I want to talk about that is it's very, that's what most people

:: 01:16

think of when they think about injury risk is like, oh, how do I adjust someone's

:: 01:20

alignment to keep them as safe as possible?

:: 01:24

The second thing I want to look at is the relationship of load to injury risk.

:: 01:30

And so these things, the alignment and the load overlap quite a lot.

:: 01:35

And so we need to consider them together.

:: 01:39

So the first thing I want to really,

:: 01:44

I think, and really the number one thing that I want to share with you is the

:: 01:48

concept of anti-fragility and that

:: 01:51

asking the question of how important is alignment, how important is load,

:: 01:57

really both of these questions kind of miss the point,

:: 02:02

that there's not one ideal kind of setting for alignment and load to prevent

:: 02:09

injuries in Pilates or in any area of life.

:: 02:13

Because obviously we want to keep people safe in the Pilates class,

:: 02:16

but we also want to keep them safe the rest of the time when they're outside of the Pilates class.

:: 02:20

And many of us think of Pilates as amazing preparation for doing life.

:: 02:26

And so part of that is reducing chance of injuries or recovering from injuries.

:: 02:30

And so the idea that there's one kind of fixed you know,

:: 02:34

rule of alignment or rule of loading that prevents injuries is is just it misses

:: 02:39

the point and here's why because humans,

:: 02:42

are not fragile we're anti-fragile and anti-fragile is a coin a term coined by um nasim taleb.

:: 02:51

And what he means by that is something that gains by stress.

:: 02:57

So let's think about the three examples that I think illustrate this really

:: 03:01

well that Nassim Taleb uses.

:: 03:04

First, there's something that's fragile. Now, something that's fragile,

:: 03:08

almost any stressor is likely to make it worse.

:: 03:13

So think about your grandma's crystal vase that's been sitting in the cabinet

:: 03:17

it untouched for 20 years because it's too precious to use because you might break it.

:: 03:23

So anything you do to that, if you knock it, if you pick it up,

:: 03:27

if you drop it, if you walk past it and brush past it, it's not going to make it better.

:: 03:32

It's only going to, there's a chance that you're going to damage that with every

:: 03:37

time you knock it, the only possible outcome is it stays the same or it gets worse.

:: 03:41

And the harder you knock it, the more worse it's going to get.

:: 03:45

And when we think of something that's fragile and we think of the opposite of

:: 03:48

fragile, often people think of like resilient or robust.

:: 03:51

And that is something that's very tough and can withstand a lot of stress.

:: 03:55

I think about like one of those, I always think of those tough Tonka toys.

:: 04:01

I'm not sure if there's a brand anyone outside of Australia had,

:: 04:03

but these kind of really tough, rough and tough kind of tip trucks and things

:: 04:07

that I had when I was a kid that, you know, they're made for young kids and you can throw them.

:: 04:12

You can step on them, you can leave them out in the garden for three months

:: 04:16

in the rain, and they're totally fine. They just keep going through it all.

:: 04:19

And so these are very robust, they're very resilient. They can tolerate a lot of abuse.

:: 04:25

But that's not actually the opposite of fragile because fragile things,

:: 04:30

any kind of stress makes them worse.

:: 04:33

Whereas a robust thing, stress doesn't make it worse, but it doesn't make it better.

:: 04:38

So the opposite of something that's fragile is something that stress actually,

:: 04:41

it requires stress to thrive.

:: 04:44

And so that is humans, humans and all organic life.

:: 04:50

For example, if you take a human and you put them in bed and don't let them

:: 04:57

move for six weeks, they do not get stronger. They get weaker and they don't

:: 05:01

get more healthy. They become sicker.

:: 05:03

And so how to make humans more resistant to stress, we actually have to apply stress.

:: 05:12

And that's what we do for a living. We apply stress to the body in the form

:: 05:16

of resistance from the body weight or the springs on the Reformer or the Cadillac

:: 05:20

or whatever, and that stress stimulates the body to become stronger.

:: 05:27

So the stress makes us stronger, the opposite of fragile.

:: 05:33

Now, why is this important?

:: 05:39

Because if you apply stress to something fragile, you're only going to do it harm.

:: 05:44

Whereas if you apply stress to something anti-fragile, like humans,

:: 05:48

you're going to make them stronger.

:: 05:50

Now, there's a limit to how much stress humans can tolerate,

:: 05:54

and so you have to apply the right amount of stress at the right time.

:: 06:03

But stress is actually what makes us stronger.

:: 06:08

And when we're stronger, we're more resistant to injury.

:: 06:14

Because injury occurs when a body tissue, whether it's a ligament,

:: 06:20

a tendon, a muscle, fascia,

:: 06:23

bone, whatever it might be, is subjected to a load beyond its capacity to tolerate.

:: 06:31

And so if you subject the hamstrings to a load that they can't tolerate you

:: 06:37

get a hamstring tear if you subject a spinal disc to a load it can't tolerate

:: 06:42

you may have a disc injury,

:: 06:47

so how do you prevent injuries well do you avoid loading the hamstrings well

:: 06:52

how would you avoid loading the hamstrings send somebody to bed and don't let

:: 06:55

them move is that going to make them more resistant to injury no it's not it's going to make them.

:: 07:01

More vulnerable to injury. So how do you make somebody less likely to get a

:: 07:06

hamstring injury? You strengthen the hamstrings. How do you strengthen the hamstrings?

:: 07:10

You apply stress to the hamstrings in the form of load.

:: 07:14

So load is what too much load can cause an injury because the tissues can't tolerate it.

:: 07:22

Not enough load can predispose to injury because it causes the tissues to become

:: 07:27

weaker and reduces their load tolerance. So then when you do load it,

:: 07:31

you're more likely to injure it.

:: 07:33

The right amount of load at the right time reduces the likelihood of injury

:: 07:39

quite substantially because it increases the strength and resilience of those

:: 07:43

tissues and their ability to tolerate load.

:: 07:47

So with injury prevention, the question of what is the right load and what is

:: 07:58

load dangerous is not the right question.

:: 08:01

The right question is, how much load is the right amount to apply right now?

:: 08:07

And load is very, very specific. So if you want to prevent hamstring injuries, you should,

:: 08:16

apply load in the positions where the hamstring is vulnerable to injury.

:: 08:19

Now, you need to apply progressively and start with what the tissues can currently tolerate.

:: 08:26

But.

:: 08:29

If you want to make your spine robust to injuries during spinal extension or

:: 08:36

injuries during rotation or injuries during flexion, well, you need to apply load

:: 08:41

in those positions progressively, starting with what the person can currently

:: 08:44

tolerate and then progressively loading over time,

:: 08:48

to build up tolerance in those tissues.

:: 08:50

When I say tolerance, I mean the tissues literally get bigger, thicker, stronger.

:: 08:54

Like we have decent evidence, I mean, everybody understands that muscles get

:: 08:59

bigger when you load them,

:: 09:01

but it's also true that tendons, ligaments, discs, and bones,

:: 09:07

and connective tissue in general, get bigger and thicker and stronger when we,

:: 09:13

load them progressively and repeatedly over time.

:: 09:18

So with load and with alignment there is no one single rule that says you know

:: 09:26

this particular alignment or this particular load is ideal to avoid or prevent injuries,

:: 09:34

really what we want to do is progressively load all positions over time starting

:: 09:40

with the client what the client concurrently tolerate, and then progressively

:: 09:43

adding load to increase tolerance.

:: 09:46

Now I'm going to talk through some examples of this.

:: 09:56

There was a, I'm going to put a bunch of studies in the show notes.

:: 10:00

I'm not going to talk about every particular study in my little monologue here,

:: 10:05

but I'll put a bunch of studies in the show notes.

:: 10:07

So we have quite a few studies showing prospective differences between levels

:: 10:14

of strength predicting future injuries.

:: 10:16

So people with low strength have more injuries later.

:: 10:20

So if we measure a bunch of people's hamstring strength, for example,

:: 10:24

and then follow them for a year and we see who gets a hamstring injury,

:: 10:29

guess what? The people with lower hamstring strength at baseline had more injuries

:: 10:34

subsequently over the year.

:: 10:36

Uh and we see the river we can see the reverse as well um that,

:: 10:47

uh athletes who have a stronger squat so can squat more than 2.2 times body

:: 10:55

weight for males or 1.6 times body weight for females,

:: 10:58

have fewer lower body injuries in football softball and volleyball or put another

:: 11:03

way we could frame that exactly as the opposite,

:: 11:05

athletes who are not strong in their lower body, who are less strong in their

:: 11:09

lower bodies, have more lower body injuries.

:: 11:13

So if you want to predict how likely someone is to get injured in football or

:: 11:17

softball or volleyball, get them to squat and see how much they can squat.

:: 11:22

If they're a female and they can't squat 1.6 times their body weight,

:: 11:25

they're more likely to get injured.

:: 11:27

So by keeping our clients weak, by avoiding squatting maybe because we think

:: 11:32

it's dangerous, we're actually increasing the chance of them becoming injured,

:: 11:37

because humans are anti-fragile,

:: 11:39

and we actually require stress and load in order to thrive and become stronger.

:: 11:45

And we see that with a couple of quite substantial.

:: 11:53

Systematic review and meta-analysis that have come out over the last few years.

:: 11:56

There's one from 2018 by Lauson et al, which found that a 10% increase in strength

:: 12:03

training volume reduced injury risk by 4%.

:: 12:07

So increase it by 20%, reduce injury risk by 8%. Increase strengthening training

:: 12:12

volume by 30%, reduce injury risk by 12%, etc.

:: 12:16

And so this systematic review from 2018 from Lawson,

:: 12:22

Well, the title of the paper is a little bit of a giveaway. It's called Strength

:: 12:26

Training as Superior, Dose-Dependent and Safe Prevention of Acute and Overused

:: 12:30

Sports Injuries, A Systematic Review, Qualitative Analysis and Meta-Analysis.

:: 12:37

And so what they found was in the title that a very robust relationship between

:: 12:46

strength training and injury risk. Now, most of these studies were on actual hamstring injuries.

:: 12:51

So we we can't draw conclusions necessarily to every single possible injury

:: 12:55

but we have a bunch of other studies supporting this with some of which i'll

:: 12:58

cite today um there's a second meta-analysis by i'm not going to well i'm going to attempt,

:: 13:05

the the uh the name it's by klub bachowski et al uh,

:: 13:13

and from may 2026 so just a month ago at the time of recording this is called

:: 13:18

exercise-based strategies from warm-up to training, a systematic review of performance

:: 13:22

enhancement and injury prevention.

:: 13:23

What they found was that two forms of exercise, both neuromuscular warm-ups

:: 13:30

and strength training, were the most effective injury prevention.

:: 13:34

But when they look at the actual neuromuscular warm-ups they use,

:: 13:38

they were basically the FIFA 11+, which is the soccer warm-up,

:: 13:41

which has a lot of strengthening.

:: 13:44

There are all kinds of side bridges and adductor bridges and,

:: 13:49

you know, things like that in there and sprints and things like that.

:: 13:51

So it's pretty high load that neuromuscular warmup, I would call it a high load,

:: 13:58

or a strength-based neuromuscular warmup. So basically.

:: 14:04

The best quality and most recent research we have strongly supports this notion

:: 14:14

of anti-fragility and that's strengthening people's tissues and,

:: 14:19

protects those tissues that are strengthened against subsequent injury.

:: 14:24

And the idea of antifragility is also supported by the training on overuse injuries,

:: 14:35

by the research on overuse injuries in athletes.

:: 14:38

And so this is from the literature looking at typically ball,

:: 14:45

like grass team ball sports like football, et cetera, rugby,

:: 14:49

where they look at, they can do these, they can track exercise volume very easily

:: 14:55

because people like the players wear GPS trackers and they know how many miles

:: 14:58

they run each week, like when they're playing and training.

:: 15:01

And so what they found, what this literature consistently shows is that too

:: 15:08

little for too long followed by too much too soon is what causes injury.

:: 15:14

So in other words, big increases in training volume and or intensity increase

:: 15:19

the risk of injury. So if you apply an unaccustomed load that somebody's not

:: 15:23

able to tolerate, that increases the risk of injury. But-

:: 15:28

Athletes with consistent high workload suffer fewer injuries.

:: 15:33

So people who are conditioned to tolerate high loads because they habitually

:: 15:38

subject their tissues to high loads actually have fewer injuries.

:: 15:41

So the notion of overuse injuries is mostly, I think, I would say misapplied.

:: 15:50

So of course it's possible to get an overuse injury. I mean,

:: 15:53

if you did like 10,000 deadlifts in 24 hours, you would have almost 100% chance of getting an injury.

:: 16:00

So there is such a thing as overuse injuries, obviously.

:: 16:03

But I think we set the bar way too low for what the body can tolerate and in

:: 16:10

fact, what the body requires to thrive and become stronger.

:: 16:14

So I think in general,

:: 16:18

in Pilates as well as in exercise science and physiotherapy,

:: 16:22

we're way too conservative in what we prescribe for our clients in terms of

:: 16:27

exercise because we want to avoid overuse injuries.

:: 16:30

Actually high habitual training volumes, even like in elite athletes,

:: 16:35

like these people are running ridiculous amounts of distance and training ridiculously

:: 16:40

hard, predisposed to fewer injuries.

:: 16:45

So it's only high big spikes in training volume that are more associated with injuries.

:: 16:53

And then we have a bunch of literature on alignment that says that activities

:: 16:59

that have extreme positions in them like yoga, like breakdancing,

:: 17:08

like CrossFit, like,

:: 17:11

actually have relatively low injury rates. So yoga has lower rates of injuries

:: 17:19

compared to like just other general physical activities.

:: 17:24

Breakdancing, which is people just contort themselves into incredible positions.

:: 17:30

Just go to YouTube and type in like breakdancing competition.

:: 17:33

There's just some incredible work that they do.

:: 17:36

It's safer than badminton, safer than cycling, safer than sailing.

:: 17:40

And CrossFit, where people are, you know, flinging themselves through keeping

:: 17:43

pull-ups and doing, you know, tyre flips and handstand push-ups and all kinds of weird positions.

:: 17:53

Have very similar injury rates to Olympic lifting, where people use very,

:: 17:59

very precise technique under very controlled conditions.

:: 18:04

Um in fact crossfit have way fewer injuries than running soccer and even cricket,

:: 18:11

which is a pretty pedestrian sport um according to most people um,

:: 18:16

the there's not a really good relationship between running biomechanics and

:: 18:22

running injuries in fact it's just mileage that predicts injury risk in running.

:: 18:30

And even with, you know, just things with technique within the activity,

:: 18:38

like I mentioned right at the top, knees going in during a squat,

:: 18:42

that there's actually not really any good evidence that that causes injuries.

:: 18:46

In fact, if you just, again, do a YouTube

:: 18:50

search for powerlifting squat championships or something like that.

:: 18:58

You'll see a large number of elite strength athletes when they squat, their knees go in.

:: 19:07

And so that's probably not bad technique. In fact, I did a whole episode a while

:: 19:11

back, which I'll link to in the show notes, can't remember which one it was,

:: 19:14

talking about the biomechanics and the literature on why the knees going in

:: 19:18

the squat might actually be

:: 19:21

something that increases strength and reduces injury risk during a squat.

:: 19:28

And there's a 2020 systematic review of meta-analysis that,

:: 19:32

looked at this question specifically and concluded that knees going in during

:: 19:39

a squat doesn't increase injury risk. We have got no evidence that it does.

:: 19:45

So besides that, we've got multiple large meta-analyses that have shown that

:: 19:54

spinal flexion does not predict back injury.

:: 19:56

In fact, people with more back pain tend to lift with a straighter back.

:: 20:02

And in fact, the belief that moving wrong is dangerous correlates with more pain.

:: 20:09

So in summary, now, I mean, there's many more of these studies.

:: 20:14

So, you know, for example, poor scapular mechanics, you know,

:: 20:17

in quotes, don't predict shoulder injuries and I'll link to most or all of these

:: 20:22

studies depending on how sick I get of copying and pasting them into the show notes.

:: 20:28

But so in summary, Sorry.

:: 20:31

Load, too much load applied to tissues that can't tolerate that load causes injuries.

:: 20:38

Not enough load causes the tissues to become weak and vulnerable to injury.

:: 20:44

So load is both the poison and the medicine because load applied progressively

:: 20:50

over time strengthens the tissues and increases their load tolerance and resistance to injury.

:: 20:56

So it protects against injuries. So too much load, too soon,

:: 20:59

after too little for too long, causes injury.

:: 21:03

Load applied progressively over time reduces the chance of injury or protects

:: 21:08

against injury because humans are anti-fragile.

:: 21:11

And so should we be careful of loading people in extreme positions?

:: 21:17

Yes, if they're not conditioned to tolerate those positions.

:: 21:21

But we should be careful of loading people in any position they're not conditioned to tolerate.

:: 21:25

We should start with a load that they can tolerate and progressively build that load over time.

:: 21:31

And I would argue that it's perfectly safe and in fact probably a lot safer,

:: 21:36

to progressively load someone in extreme spinal positions like flexion,

:: 21:42

rotation, extension, whatever.

:: 21:46

And because that will build up top progressive tolerance to that,

:: 21:50

those positions in their spinal tissues, not just the disc, but the bones,

:: 21:54

the ligaments, the tendons, the muscles, all of the above.

:: 21:57

And just anecdotally, I mean, I do that with my spine.

:: 22:00

I do full range extension, like full backbend as far as I can bend down to full

:: 22:08

flexion as far as I can flex with as much load as I can do for six or seven reps.

:: 22:14

And I think I'm currently doing on my weight stack 125.

:: 22:21

Kilos, something like that. And my back's never felt better and I'm 55 years old.

:: 22:27

And I've been doing that for quite a while. So I know that's an N of one,

:: 22:32

but don't worry, I'll front load all of the scientific papers in the show notes.

:: 22:36

So dear listener, how do we keep our clients safe? Well, I think the answer

:: 22:41

to that is teach them Pilates through full range.

:: 22:45

Don't fear any positions. There are no dangerous positions. There are no wrong positions.

:: 22:51

There are only positions we're unaccustomed to. And so when introducing a new

:: 22:55

position that someone is unaccustomed to, be, I would say.

:: 23:04

I want to choose the right word here.

:: 23:09

Begin with something that you're confident they can tolerate.

:: 23:15

Wait and see how they pull up a couple of days later. If they tolerate it,

:: 23:18

add 10% next time and go again. And just keep going until they reach a point

:: 23:24

where they're like, oh, this is really freaking hard.

:: 23:27

And then just give them adequate recovery in between sessions,

:: 23:30

a couple of days recovery in between sessions. and you can build up load as

:: 23:34

they're able to tolerate it.

:: 23:36

And so that is, I think, in my opinion, the way to maximize the safety of the

:: 23:43

client both in and out of the Pilates class.

:: 23:47

Because even if we avoid certain positions in Pilates, like if we took it to

:: 23:52

the extreme and never rotated our spine under load or never extended our spine

:: 23:56

under load during Pilates,

:: 23:59

Well, that person is going to do both of those things in their real life.

:: 24:04

Okay, when you pick up a kid out of the back seat of a car or you get out of a chair.

:: 24:15

Pulling the washing out of the machine, there are constant situations multiple

:: 24:21

times every day where pretty much every single one of us rotates,

:: 24:25

flexes, and extends our spine under load.

:: 24:27

So just avoiding it during the Pilates class isn't going to prevent injury if

:: 24:32

rotating your spine under load is going to cause injury.

:: 24:35

The much better strategy is to actually build up a tolerance to those positions

:: 24:40

so that when they do inevitably occur in life, they're not a problem.

:: 24:44

And so that's what we would do for any other body part.

:: 24:46

If you're rehabbing an ACL in the knee and you want to prevent that from re-injuring, what do you do?

:: 24:52

You build up a tolerance to the previously injurious stimuli.

:: 24:54

So you have to eventually be able to do direction change in weird angles and

:: 24:59

positions and rotation of the knee.

:: 25:03

Under load at speed. Because if people want to get back to playing sport,

:: 25:06

that's going to occur on the field and they have to be able to tolerate it.

:: 25:09

And how do you get them to tolerate it? Well, you have to start with a low amount

:: 25:13

of load at a slow controlled speed and gradually, gradually over time,

:: 25:17

build up the load and the stimulus and the stress in those positions and build up the tolerance.

:: 25:23

And that, I mean, that's Rehab 101 and Rehab and Injury Prevention are the same

:: 25:28

thing because they're both about building up tissue tolerance to a potentially injurious stimulus.

:: 25:35

And rehab is just where there already has been an injury.

:: 25:39

So we want to build up a tolerance to the same exact stimulus that caused the

:: 25:42

injury so that in future, that same stimulus won't cause another injury.

:: 25:46

Whereas in injury prevention, it just hasn't happened yet.

:: 25:50

So we want to build up a tolerance to that potentially injurious stimulus before it causes an injury.

:: 25:56

But the process is exactly the same. You just gradually build up tolerance to

:: 26:03

the thing that you're worried about causing an injury.

:: 26:06

The poison is the medicine with injury prevention and with rehab, it's the same thing.

:: 26:12

All right, dear listener, keep safe, bend your spine, under load progressively,

:: 26:18

start with what you can do, keep progressing it, keep getting stronger,

:: 26:22

keep getting more awesome and I'll see you in the next one.