Training a client with a chronic injury is no small task. This is especially true if a client is injured and the injury has gone undiagnosed and, as a result, untreated. It is generally outside the scope of practice for a personal trainer to diagnose or treat an injury. Personal trainers are not, by education and license, diagnosticians or physical therapists. Rather, personal trainers are “suspect-itians.” In other words, personal trainers might have an inkling or idea of what could be causing some discomfort based on a client’s description (e.g., tendonitis, shin splints), but health and fitness professionals are not (as a general rule) qualified to say: “You have X and you need to do Y.” (Note: The exception to this rule is a personal trainer who possesses the requisite skills and licensure, such as an athletic trainer license or other acceptable certification, to operate outside of this generalization.)

It is generally considered best practice for personal trainers to refer a client with a suspected chronic injury to a treating physician who can make a second referral to an orthopedic professional, physical therapist or athletic trainer. To remain within your identified scope of practice, do not try to diagnose or treat the suspected injury yourself. It is recommended to obtain medical clearance so that any exercise recommendation you make or program you design will not aggravate an existing condition. Use the prescribed exercises provided by the medical professional and incorporate other appropriate activities to balance the program (e.g., flexibility, mind-body exercises).  

When it comes to working with clients who have had a previous injury and/or suffer from continuous complications from an unhealed or recurring injury, there are considerations to keep in mind while staying within your scope of practice. A few of the most common injuries you may encounter include:

• Bursitis
• Fractures
• Torn muscles or ligaments
• Sciatica
• Shin Splints
• Tendinopathy
• Tennis Elbow

General Signs of a Chronic Injury

According to the National Institutes of Health (NIH), common signs of chronic injuries include pain during activity, pain or an aching sensation when at rest, and swelling at the site of injury. While there are “at-home” remedies and treatment options for acute injuries, it is advised to seek medical treatment under the following circumstances (National Institutes of Health, 2016):

• Severe pain, swelling or numbness
• Inability to place weight on the area
• Pain accompanied by increased swelling, instability or joint abnormality

Bursitis

What is it? Bursitis is an inflammation or irritation of the bursa sacs, which are small, fluid-filled cushions situated between bones or other moving structures. Most commonly, bursitis is caused by overuse, repetitive movements or direct injury to a joint (National Institutes of Health, 2016).

Bursitis is seen in the knees, shoulders and the ankle, and isn’t limited to professional or recreational athletes. Certain occupational hazards or repetitive movements can place someone at high risk for bursitis. Carpenters and gardeners, for example, perform repeat motion on a daily basis and may be at higher risk for bursitis.

How is it treated? The primary goal is to reduce and stop the irritation and inflammation using a variety of protocols and anti-inflammatory medications (e.g., aspirin, ibuprofen). Protective devices are sometimes recommended by a doctor or physical therapist to help reduce irritation to the area. Some bursitis cases are caused by an infection, which needs medical attention.

As with most injuries, rest, compression and elevation of the affected area are often suggested. Using ice isn’t as effective in resolving chronic bursitis, but may be effective for an acute injury. Any activities or exercises related to the injured area are restricted until the condition is addressed and properly treated.

What are the exercise considerations and suggestions?

• Always obtain exercise recommendations and restrictions from the client’s doctor and do not operate outside of those guidelines until the client is cleared to do so.
• Incorporate gentle stretching.
• Return to activity slowly and gradually.
• Work to strengthen the muscles of the affected joint.
• Cushion the affected area and use soft surfaces.
• Take breaks from repetitive movements.
• Stop any and all activities that result in pain.
• If the condition does not improve, recommend the client seek further treatment and modify the program accordingly.

(National Institutes of Health, 2016)

Fracture

What is it? A fracture is a complete or partial break in a bone. Fractures can be stable (broken ends line up and are minimally out of place), open, compound (skin is pierced by bone), transverse (horizontal), oblique (angled fracture pattern), or comminuted (bone shatters in three or more pieces).

Fractures are caused by trauma, disease of the bone (osteoporosis) or overuse.

How is it treated? Treatment depends on the type and severity of the fracture. If a fracture is less severe, the bones are set and immobilized in a cast; more severe fractures may require surgery. Rehabilitation is often required.

What are the exercise considerations and suggestions?

• A suspected fracture needs to be evaluated by a qualified medical professional. No activity should take place before this step is completed.
• Following the healing process, activity and movement will still be limited and the muscles surrounding the injured area will likely have atrophied, requiring a restoration of both strength and flexibility.
• If the client saw a physical therapist and completed that program, obtain the exercise recommendations and implement them accordingly.
• Do not attempt to work with a client who has an active, untreated or healing fracture unless you are working with them as part of their rehabilitative program designed by a physical therapist. Adhere to those guidelines until the client is cleared for normal activity to resume.

(American Academy of Orthopedic Surgeons, 2013)

Muscle Tear

What is it? Muscle tears, including tears in connective tissue (think cruciate ligaments), are common injuries in both recreational and performance athletes. An individual suffering from a strained or torn muscle may present with reduced strength, bruising, swelling and significant pain. The muscle may also appear to have a defect upon examination.

Muscle tears are classified into three categories:

• A Grade 1 tear is considered mild and involves less than 5% of the muscle fibers. There is minimal loss of strength and motion and this type of tear generally heals in two to three weeks.
• A Grade 2 tear is more extensive, but the muscle is not fully torn or ruptured. However, individuals with a Grade 2 tear experience a significant loss of strength and mobility. Healing time for this injury can be up to three months.
• The final category, a Grade 3 tear, is a complete rupture of a muscle and/or surrounding connective tissue. Injuries in this grade often require surgical repair and extensive physical or occupational therapy.

How is it treated? Treatment depends on the degree of muscle or connective tissue injury and if surgery is required. Many less-severe cases can be treated with anti-inflammatory medications and the RICE method (rest, ice, compress, elevate). If it is a mild injury, the individual can return to activity when range of motion is restored and pain subsides. If the injury is more severe and surgery is required, the individual will be advised to complete a physical therapy program before resuming normal/previous activities. The rate of healing can vary widely between individuals.

What are the exercise considerations and suggestions?

• Make sure the client is cleared to exercise by the treating physician and physical therapist. Most individuals who complete a physical therapy regimen will “graduate” with a list of exercises to do on their own; incorporate these into the program you design.
• Stop the exercise if the client experiences pain.
• Use exercises that target and strengthen the muscles of the affected area, but make sure the program is both balanced and comprehensive to avoid reinjuring the site and/or creating muscle imbalances in other areas.
• Follow the 50% rule: When a client is ready to return to exercise, reduce the previous volume and intensity by half. There’s no concrete recommendation that works for every client, but a conservative approach will ensure the client is safe.
• Emphasize after-session and at-home flexibility exercises. Keep in mind that full range of motion may not be fully restored due to scar tissue accumulation at the site of injury/surgery.

Sciatica 

What is it? Sciatica refers to pain felt radiating from the hip and down the back and outer thigh regions and is caused by pressure on the sciatic nerve. The culprit is usually a herniated disc. Sciatica can also be caused by a condition called spondylolisthesis, which is the dislocation of lumbar vertebra (National Institutes of Health, 2016).

How is it treated? Treating back pain requires more than a simple “do this, not that” approach. First, it depends on what is causing the back pain. If the cause of the pain is a ruptured disc, for example, surgical treatment may be required. Other chronic back pain issues not requiring surgical intervention are treated with a combination of heat/ice, exercise, flexibility training and medications.

Before developing programming for a client with chronic back pain, confirm the diagnosis with a doctor. The client may require an MRI or other diagnostic test that you, as the personal trainer, cannot provide. The following exercise considerations are for those clients who do not need surgery for their back pain.

What are the exercise considerations?

• Suggest water exercise to relieve pressure on the spine.
• Incorporate an adequate stretching routine to restore flexibility.
• Consult with a physical therapist for specific stretching exercises to include in the client’s program.
• Reinforce the importance of being physically active (movement reduces inflammation) and help the client find new ways to incorporate more activity throughout his or her day (limit prolonged periods of sitting and avoid excessive bending and twisting movements).

(National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2016; American Academy of Orthopedic Surgeons, 2013)

Shin Splints

What is it? While the term shin splints is commonly used to describe any lower leg pain, the most accurate description is pain experienced along the tibia (large bone of the lower leg). As with other types of injuries, this is often a result of overuse and is typically seen among runners. However, it may occur for other reasons such as improper footwear, aggressive increase in activity over a short period of time, poor form and technique, lack of warm-up, poor flexibility, overtraining, performing running or jumping activities on inflexible or hard surfaces, and over-pronation during running. 

The pain and discomfort associated with shin splints is most often anterior (front outside section of the leg and radiates into the foot/ankle area) or medial (inner edge of the lower leg by the calf muscles).

How is it treated? After confirming a diagnosis with a doctor, the next step is to stop the activity and allow the shin to heal properly (up to two weeks). Apply ice to reduce inflammation and implement a quality stretching program targeting the Achilles and lower-leg musculature. It is also possible to wrap the leg using an ace bandage or athletic tape for a period of time until the pain subsides, but this isn’t likely to speed the rate of recovery. If the pain persists, it could be more than shin splints and may actually be a stress fracture. Keep this in mind if your client continues to experience discomfort.

What are the exercise considerations?

• Encourage the client to confirm the diagnosis with a qualified medical professional.
• Reduce the program activity and integrate other cross-training activities (e.g., swimming, elliptical). The goal is to have the client engage in activity that doesn’t exacerbate the discomfort.
• Suggest that the client obtain footwear that offers maximum support.
• Stretch the calves and Achilles regularly to enhance flexibility at the foot-ankle joint.
• When the client is ready to return to running (or the previous activity), start and progress slowly.

(National Institutes of Health, 2016; Gotlin, 2008)

Tendinopathy 

What is it? Quite literally, tendinopathy means “disease of the tendon;” however, it is a broad term used to describe the pain and tenderness at or around a tendon that occurs from overuse. It can also mean inflammation (tendinitis) and micro tears (tendinosis). The symptoms of this condition may resemble those of bursitis or tennis elbow (see following injury). The causes are often the same or similar as well (e.g., improper equipment, poor technique, repetitive movement, not enough recovery time).

How is it treated? Most cases can be treated with at-home therapies such as rest, ice and anti-inflammatory medications. Depending on the severity of the condition, other therapies may be required or suggested by the treating physician.

What are the exercise considerations and suggestions?

• Take a break from the aggravating activity.
• Check the client’s form and technique.
• Implement cross-training activities to prevent a recurrence.
• Emphasize a proper warm-up and flexibility routine.
• Once the pain subsides, slowly progress. If the pain returns, suggest that the client follow-up with his or her treating physician and physical therapist.

(National Institutes of Health, 2016)

Tennis Elbow

What is it? Tennis elbow, or lateral epicondylitis, is persistent pain in the elbow brought on by overuse, such as the repetitive movements used in racquet sports or certain occupations such as painting, carpentry or cooking. Clients with this condition complain of a burning sensation on the outer edge of the elbow, which is typically accompanied by weak grip strength.

How is it treated? Some cases of tennis elbow require surgical intervention. Other less severe cases can be treated with a combination of therapies, including strengthening and flexibility exercises of the forearm muscles, anti-inflammatory medications, braces, shock wave therapy, physical therapy, steroid injections and, of course, rest.

What are the exercise considerations and suggestions?

• Encourage a break from the sport or activity that contributed to the condition. If it is occupationally related, the client may need to use a brace or seek specific treatment for his or her symptoms.
• When the client can obtain full and pain-free range of motion, initiate strengthening exercises focused on the muscles that can stabilize the upper body and reduce strain and stress on the elbow joint.
• Emphasize strengthening and flexibility exercises for the forearm and wrist extensors.
• Incorporate some cross-training activities to keep the client from losing fitness gains.
• If the client chooses to return to tennis (or other sport or activity), suggest that he or she have their racquet and grip assessed. Injuries often result from improper use of equipment or a poor fit.

(American Academy of Orthopedic Surgeons, 2015; Gotlin, 2008)

Chronic injuries are neither fun to have nor easy to overcome; however, with a strategic approach supported by the right medical guidance and proper training technique, your clients can achieve their health and fitness goals. That said, training a client with a chronic injury requires more time and patience on both the part of the personal trainer and the client. It may be frustrating at certain points along the training continuum, but the key is working through those frustrations together, using open and honest two-way communication and continuing to consult with the primary care physician, physical therapist or athletic trainer. Although it is not within a your scope or practice as a personal trainer to cure or rehabilitate an injury, it is, however, your job to safely and effectively apply the exercise guidelines, recognize contraindications and know when to refer to a more qualified health professional. Stay within your scope and stay committed to providing quality services.

References

American Academy of Orthopedic Surgeons (2013). Orthoinfo.

American Academy of Orthopedic Surgeons (2012). Orthoinfo.

Gotlin, R.S. (2008). Sports Injuries Guidebook. Champaign, Ill.: Human Kinetics.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (2016). Health Information.

National Institutes of Health (2016). National Institutes of Health. Bethesda, Md.: National Institutes of Health.

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