A Corrective Exercise Specialist’s Guide To Training Clients Through Pain And Injury | thePTDC | Training Through Injury
A version of this article originally appeared on willlevy.com.
You can’t go a day without seeing the latest “corrective” exercise certification or workshop being advertised on social media. Clients and athletes will inevitably turn up to a training session with a wide array of aches and pains. It’s a precarious time for a trainer, and corrective exercise is one reason why.
The Corrective Exercise Pitfall
Every weekend fitness professionals around the world are turning up to these courses in droves to have their egos inflated. They risk being led down a slippery and dubious slope through postural screenings, movement assessments, and exercise prescriptions with the intent of correcting their clients and saving them from the perils of “movement dysfunction” .
The result has been the rise of the pseudo-physio: the trainer who believes that they are as equally equipped to deal with injury and pain as the physiotherapist who spent at least four years at university learning their craft, all because said trainer attended a weekend course that gave lip service to self-myofascial release, Trendelenburg gait, and scapulohumeral rhythm.
Aside from doing a disservice for the client – who came to the personal trainer for guidance in achieving any or all of looking/feeling/moving/performing better, and not to be treated as a rehabilitation patient – this also drags a trainer well outside of his scope of practice.
If a trainer is not adequately qualified and insured to treat an injury or painful condition, or to lay hands on a client with the intent of mobilising or manipulating joints or tissues, then doing so obviously dictates that said trainer is leaving themselves wide open to liability for any damage caused.
If a client was to take an unfortunate turn and regress in their health in the time following a session with their trainer who had used any of these techniques that are not within their scope of practice, even if it was actually due to coincidental timing and nothing to do with what the trainer had actually done, then the trainer will have a very, very tough time pleading their case when a legal proceeding inevitably ensues.
And what would it all be for?
Many times, I’m sure the trainer has genuinely been led (fooled) into believing that they were doing the best for their client. Unfortunately, good intentions count for little when harm is actually caused.
It’s really unfortunate that so many fitness professionals are heading down this misinformed path, and equally so that more experienced fitpros are often the ones leading them there. Because not only is it an unnecessary risk for both the client and the trainer, it also makes the trainer less effective at their job.
Want to impress your client?
Quit worrying about “activating” your clients’ glute medius and serratus anterior, and instead build a massive arsenal of exercise variations and tweaks, and learn how and when to use which training technique to gain the desired training effect.
Your client will be infinitely more satisfied if you can show them how to use good training technique, throw some weight around, work hard, and get stronger in a pain-free manner, instead of telling them how bad their posture is, and banishing them to performing nothing but remedial exercises (which very likely aren’t going to “fix” much, if anything, because a lot of painful conditions are far more complex than merely biomechanical issues). Not only that, but you will actually get better results, because remember, your client never came to you for injury rehabilitation in the first place!
Want to be a great trainer? In addition to outstanding communication skills, excellent technical knowledge (anatomy, physiology, biomechanics, nutrition), and a willingness to actually get in there and coach, a trainer needs plenty of practical know-how. This includes program design and exercise selection, the latter of which is the second focus of this article.
So if a client is suffering from an injury or pain, after gaining clearance to ensure it’s nothing more sinister, work around it.
Personal Trainers Can Help Clients in Pain
While it’s worth keeping at the forefront of your mind the maxim “If it hurts, don’t do it” which I believe can be originally attributed to Coach Dan John, it’s also worth understanding – and helping your client to understand – the difference between pain and discomfort, and figuring out when it’s okay and necessary to push the envelope a little.
Delving further into these specifics would lead to a separate discussion on graded exposure, a concept that a trainer would be best working through under the guidance of the client’s caring medical professional to discern what or how much is acceptable, and what is not.
Another way of addressing this with your clients is through an idea that I learned from pain science expert Dr. Jason Silvernail. Have your client report to you their level of pain during exercise through a traffic light system:
- Green = no pain
- Orange = wariness, discomfort or low level pain but manageable for now
- Red = pain, something feels wrong (graded exposure would basically be the process of becoming accustomed to actions that cause Red until they become Orange, and Orange to become Green).
In practice, a scenario might be that your client is performing a step up and has a history of knee pain:
Trainer: “How is that feeling?”
Action: Carry on, and progress as able.
Action: Encourage and reinforce that their technique looks good or, if it doesn’t, verbally or manually cue them into a better technique.
Action: If there was no obvious reason for the pain, e.g. their knee wasn’t collapsing into excessive valgus, then rest, lower the weight, lower the step height, reinforce technique, and try again.
If the client calls “Red” again, abandon the exercise without losing any more training time, and opt for something else that will yield a similar training effect in a pain-free manner, perhaps something like a single leg RDL.
Treating this pain is now the job of a physiotherapist.
If adjusting on the fly like this is beyond your current capabilities, then reverting back to Dan John’s advice would be wise. Or, try out some of the techniques below.
With that said, here are a few tips and tricks that I’ve either discovered – usually through necessity – or pinched from other fitpros, for making better exercise selections or tweaking traditional ones, when dealing with common painful complaints you’ll likely encounter while training your clients.
A Trainers’ Guide to Training Clients Around Pain and Injury
Exercise: Split squat or lunge variation.
Client complaint: Anterior knee pain on front leg.
- Some people simply don’t have enough comfortable range of motion (ROM) in knee flexion. Others have restricted ankle dorsiflexion, which tends to transfer the sheer force that would be shared between the ankle and knee, entirely to the knee.
- Encouraging a more vertical tibia by using a verbal cue, your hand, or a shin block is very often the simple solution here.
- If the client had been performing a forward lunge or walking lunge which involves a lot of deceleration at the knee, switch it to a reverse lunge or a split squat instead, and probably still include the above vertical shin cue.
Exercise: Split squat or lunge variation.
Client complaint: Anterior knee pain on rear leg.
- Again, this is likely due to a restriction in ROM, but often seems to be a direct result of inflexibility, or “tightness” at the quadriceps (and “tightness” is a very broad term, the deeper examination of which, as well as the importance, or lack thereof, of stretching, is beyond the scope of this article).
Perform some brief SMR/foam rolling for the quadriceps, particularly focusing on rectus femoris (right in the middle of the thigh) as shown here.
*Note that this can lead us back into that murky “corrective” territory. Don’t get hung up on this. This tip often works very quickly, so give it a minute or two max. Re-try the exercise. If pain is still present, move on.
- Have the client use a greater hip hinge and a less upright posture, as demonstrated below (0.14 – 0.20 mark). This will give the rectus femoris – the quadriceps muscle that crosses both the knee and hip joints – a little more “slack”, which in turn tends to take some pressure off the knee:
- Use a shortened range of motion (ROM). Placing a Yoga block lying flat underneath where the rear knee would touch the ground is handy tip for this. Again, this will lessen stretch required by the quads, particularly the rectus femoris.
Exercise: Overhead press
Client complaint: Shoulder pain
- If using a barbell, switch to single arm work with a dumbbell or kettlebell. The unilateral option tends to allow more rotational freedom through the thoracic spine and shoulder to find a comfortable position.
- If the DB or KB press still causes pain, try angled bar pressing. The incline pressing motion – between vertical and horizontal – is a far more comfortable pressing position for most people, especially those with restricted thoracic spine or shoulder mobility.
- Press against bands. For some individuals, the shoulder pain will only be present with heavy loading in the bottom portion of the press where the shoulder joint is a bit more jammed up. Utilising the variable resistance of bands will deload the bottom range of the press and add overload at the top, where the shoulder joint frees up more.
Bands can be added to either the angled bar press by looping the band over the bar, or to single arm DB or KB pressing by performing the press from a half kneeling position with the band looped under the down knee at one end, and held in the pressing hand along with the DB or KB at the other.
- Turn the press into a push press. For similar reasons to point #3 above, the push press provides a way to “cheat” through the most difficult bottom portion of the pressing action.
Exercise: Overhead press
Client complaint: Low back pain (LBP)
- Some people will go into excessive lumbar extension when performing overhead pressing exercises – particularly when using a barbell – which may cause some extension-based low back pain. So the first port of call is simply to attempt to coach the client into a better position.
Think of the body position for a standing overhead press as being a standing plank. That is, a position that resists extension at the lumbar spine. Cue the client to squeeze their glutes hard, brace through abs while keeping their chest up, and maintain this posture while pressing.
- Failing this cueing, try switching the client to a half kneeling position. In half kneeling position one hip is flexed, making it more difficult to fall back into lumbar extension.
- Switch to a single arm DB or KB pressing variation. Much like in the shoulder pain scenario, the freedom for rotational movement offered in a unilateral press can help to work around the limitation in thoracic extension and/or shoulder flexion in the bilateral press (the ability to get both arms straight overhead).
- Failing the above options, direct vertical pressing may not be on the cards for this client. Switch to angled bar pressing instead. This will almost certainly put their lumbar spine in a very comfortable, low stress, and safe position.
Exercise: Bench press
Client complaint: Shoulder pain
- Again, our first option should be to coach better technique. Anterior shoulder pain is common in the bench press when the scapulae tilt anteriorly in the bottom position. That is, the elbows drop way back behind the body, and the shoulder blades roll forward, possibly impinging upon any number of structures within that crowded shoulder joint.
All typical powerlifting style cues work well here. Keep the scapulae retracted and depressed, i.e. back and down; actively ‘row’ the bar down and meet it with the chest, rather than merely allowing the bar to ‘fall’ down.
If that doesn’t eliminate the pain, try the following steps.
- Switch to a floor press, or board press. Maintaining the cues for the scapulae position from above, both the floor and board presses reduce the ROM at the bottom position, which is where the aforementioned impingement issues tend to be problematic.
- Substitute for dumbbells. Dumbbells allow for a neutral and variable grip compared to the barbell, again providing more opportunity to find a more comfortable movement.
- Switch to push-ups. For some, the issue isn’t resolved by having the scapulae locked into the retracted and depressed position. Rather, they will be better served in the push up where the scapulae are free-moving and allowed to work in a more natural scapulohumeral rhythm.
Client complaint: Shoulder pain
- Again, the culprit here is oftentimes some type of impingement occurring when the scapulae roll anteriorly in the bottom of the movement. The cue for the client to ‘row’ the ground toward their chest rather than just passively ‘falling’ to the ground, often works well.
- Failing a mere technique fix, bands again become handy here. For a stronger client who can perform multiple bodyweight push-ups with ease, make the push-ups bandresisted by looping it behind the back (shown below).
For clients who aren’t yet as strong in push-ups, try band assisted push-ups instead, by having them lie with their waste on top of a band looped across the pegs or J hooks of a squat rack at around knee height.
Client complaint: Anterior knee pain
- This is one of the most commonly written about painful complaints in a training context, so I won’t belabour the point again.
Generally, a more vertical tibia position is the best bet for working around anterior knee pain. Thus, box squats become a trainer’s best friend here.
A box can be used to both sit back further into the squat, creating a more vertical shin and shifting more load onto the posterior chain, and it can be used to adjust squat depth to find a pain-free ROM.
Don’t go beating square pegs into round holes. Nobody who isn’t competing in power lifting has to squat. If squatting still hurts your client, move on; trap bar deadlifts and/or single leg work may be better suited.
Exercise: Squatting, lunging
Client complaint: Ankle pain into dorsiflexion
- Working around this issue largely goes hand-in-hand with working around anterior knee pain in the same exercises: vertical tibia will usually be the key. Box squats, a verbal cue or a shin block for split squats and lunges, or switching to deadlift variations are usually safe bets.
Exercise: Split squats, lunges or step ups
Client complaint: Medial knee pain
- Pain on the medial portion of the knee usually coincides with excessive valgus stress, i.e. the knee ‘caving’ inwards.
On single leg exercises (and oftentimes this works for squatting, too) the easiest tip I’ve found for working around this problem is a method that physical therapist Gray Cook has dubbed “Reactive Neuromuscular Training”, or RNT.
Using either your hand to push the knee inwards, or holding a band to pull the knee inwards (or if the client is training themselves, tying a band to something and looping the other end around the knee, as shown below) will exaggerate the problem, or the movement mistake. In turn, the body responds reactively by applying a counter motion to resist the hand/band, effectively removing the valgus stress.
Exercise: Single leg stance
Client complaint: Ankle pain while stabilising
- This one should be obvious. If a client or athlete is returning from an ankle sprain injury and still has pain when they’re balance is challenged on the injured side, then provide them the balance they need in the interim so they can still achieve a positive training effect.
Initially they may need to stick with bilateral lower body exercises. As the injury begins to heal, they might be able to progress to staggered stance work to challenge their balance just a little bit. Then they can move on to supported single leg work, i.e. performing the exercise with something solid to hold onto for balance, until the ankle is pain-free in single leg stance with no balance aid.
Exercise: Back squats (or any back loaded barbell exercise)
Client complaint: Shoulder pain
- Some people simply can’t achieve enough shoulder external rotation to comfortably hold a straight bar on their back. This particular issues is a common one for powerlifters and has been covered plenty in writings for that crowd, so I won’t belabour the point here.
In short, first, ensure that the client understands how to extend fully through the thoracic spine – i.e. lift their chest – at the setup. That thoracic extension will “buy” some extra shoulder external rotation ROM.
- Perform some mobilisations that promote thoracic extension and rotation immediately prior to the squats. Sometimes, just a tiny bit more ROM is enough to get pain-free.
- Failing that, play with the grip. Try a wider grip, and/or a pinky-less grip, and/or a false grip (thumbs on same side of the bar as the fingers).
- If none of these produce results, a safety squat bar, some type of cambered bar, or a front squat variation may be required in the interim. If back squatting with a straight bar is important, such as for a competitive powerlifter, then these options can be used to tide them over and maintain squat strength while some professional assistance is sought, such as through a physio and/or other manual therapist.
Exercise: Deadlift (any)
Client complaint: Low back pain – in bottom position or during concentric phase of lift.
- First, this is usually indicative of flexion-based LBP, and though discogenic pathologies are more commonly associated with flexion-based pain, this doesn’t necessarily mean that a disc injury is present, or that if there is, that the disc is necessarily the culprit for the pain. And we as trainers certainly shouldn’t be scaring our clients into believing that they have a serious disc injury when we have absolutely no grounds to state such! That’s an important point to address upfront.
So as a trainer, just know that your client currently hurts in loaded flexion, nothing more. Improve technique or work around it.
Improving technique may be as simple as cueing them to get more extension and/or tighter through the back, both lower and upper. These are basic deadlift cues that I don’t feel I need to cover with this article.
- Focus on taking the slack out of the bar and upper back tightness specifically. A lot of clients when attempting to deadlift, have the tendency to try to “yank” the bar off the ground in one swift motion, rather than setting up with tension, then maintaining that tension while driving through the hips. The sudden jerk that occurs with this technique flaw tends to set of a cascade of flexion activity through the back: the shoulders roll forward, the scapulae abduct, the upper back rounds, and the lower back follows suit.
If you intend on having your clients deadlift appreciable weight, then teaching correct technique here becomes important, especially for a LBP sufferer.
- Reduce the ROM. Some clients may not have the mobility to get into the bottom position of a deadlift from the floor without rounding through the back. And much like the squat, with the exception of competitive power lifters, no onehas to deadlift a straight bar from the floor.
High handled trap bar, rack pulls, block pulls, or kettlebell deadlift variations are going to be far more suitable in this instance.
Exercise: Deadlift (any)
Client complaint: Low back pain – extension-based pain at lockout.
- The client isn’t using their glutes fully to lock out, instead maintaining the lumbar extension they set up with at the bottom, and jamming it further at lockout. Verbal cueing and physical demonstration is the first step here.
- Make sure you’ve used appropriate progressions in getting to the deadlift. I take issue with the prevalent notion that clients just need to stick to the “big basic barbell lifts”, as this usually means they’re thrown into exercises they’re simply not ready for. Yes, deadlifts can be a great exercise. However, that doesn’t mean that everyone should be pulling a straight bar from the floor on day one, or even at all.
Glute bridges, hip thrusts, and shortened ROM hip hinge patters such as kneeling deadlifts, high KB deadlifts or rack pulls should be mastered before extending the ROM and adding the technical complexity of the barbell. If your client hasn’t checked those boxes, go back and do so.
Exercise: Planks, push-ups
Client complaint: Low back pain
- Ninety nine times out of a hundred, this will also be extension-based back pain. The client is not adequately resisting extension through their lumbar spine by actively using their glutes and “anterior core”. Instead, they are passively hanging on the structural restraints of the low back, hips and, often, neck.
In plank, cue your client to contract their glutes, hard. I’ve found that a focused instruction to brace the abs is usually not required. If the client can get into the correct plank position (you may need to get hands on to help) with their thoracic spine extended (chest out), chin packed, and hips level, that the glutes are the key cue from here. Get the glutes and everything else falls into place, including the reduction or elimination of extension-based LBP.
A more effective way to plankThe plank world record was broken recently at over 4 hours! If you haven’t got that much time this variation will have you shaking in just a few seconds.By tensing your quads and glutes, and pulling your feet and elbows together as well as your abs the whole intensity of this exercise increases massively.You shouldn’t be able to hold it for more than a minute – if you can, make sure you squeeze even harder!========This video is property of Bret Contreras (Fitness Page) and is used with permission. Learn More about Bret at www.bretcontreras.com and subscribe to him on YouTube at www.theptdc.com/bretcontreras=======For more info about the PTDC, go here:http://www.theptdc.com/about-us
Posted by Personal Trainer Development Center on Monday, May 18, 2015
- Push-ups are moving planks. I add them in here because again, many trainers tend to use exercises that are too advanced for their clients, too early. If your client can’t hold a solid plank, then it’s almost impossible for them to perform a solid looking push up.
Exercise: Inverted rows, pull-ups
Client complaint: Forearm/wrist pain
- This is an odd little one that I’ve come across surprisingly often, and I understand it because I’m prone to this one myself.
Certain pulling positions can cause what I describe an “electric shock” through the wrist or forearm area, and clients’ descriptions of their pain has been consistent with this.
The lateral flexion of the wrist seems to be a key factor. Thus, a shoulder width underhand grip almost always seem to fix the issue instantly. So if you run across this complaint, give that tip a try.
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