If a potential or new client has an injury, I won’t work with her without written medical clearance from her doctor—preferably the doctor who treated her for the injury. I also recommend that the client first get physical therapy (if she has not already), so she is better educated on the “dos and don’ts” of her specific situation and more ready for mainstream exercise. In my experience, doctors don’t always prescribe physical therapy or rehab exercise, but they will often do so if prompted by their patients. Some clients don’t even know they should request physical therapy—so I feel it’s important for trainers to educate clients about it!
Physical therapists (PTs) are a wonderful resource for us trainers, because their exercise guidelines are specific and helpful—and PTs are often reachable by phone. If I need to get guidelines directly from a physician, I ask very specific questions regarding joint range of motion (ROM), resistance limits and the like; otherwise, the guidelines can be too vague to be useful (e.g., “Don’t lift anything over 10 pounds”). Getting clarification can take weeks, so it pays to ask the right questions at the outset. Also, having the client get medical clearance forms filled out usually expedites the process.
Occasionally a longtime client who has good body awareness and exercise experience will come to a session with a minor injury. If the injury is annoying but not serious, I help him figure out what may have caused it. I’ve had clients get minor injuries from moving furniture, planting bulbs, getting pulled too hard by a dog on a leash, etc. In these cases, I’ll ask if the client wants to try working out, and if he’s okay, we’ll “work around” the affected area and see if the problem resolves itself. We avoid any movement that aggravates or puts pressure on the affected area. If the injury doesn’t improve within 1–3 days, he makes an appointment to see his physician and have it evaluated. Any client who is in pain and cannot exercise gets sent home and referred to the doctor!
Upper Marlboro, Maryland
Handling a client with an injury begins with a conversation. What does it feel like? When does it bother her? While at rest? During specific motions or activities? How did the injury occur? I ask the client about her recent diet, her stress levels and her overall health. Might the complaint relate to an old injury, another pre-existing condition or medications?
In a perfect world, if there were any question as to the severity of an injury, the client would always be sent to a doctor for a checkup, to be on the safe side. And in a perfect world, getting an appointment wouldn’t take weeks or months, the client would have excellent health insurance to cover it, and the doctor would be a specialist who could give a prescription other than “Don’t exercise for 2 months.”
But in an imperfect world, how do trainers decide whether an injury deserves the effort of seeking medical care? In the end, that is a judgment call. It is always better to err on the side of safety, common sense and the client’s long-term health and fitness benefits rather than letting immediate goals and the client’s impatience dictate the course of action.
We must remember that as personal fitness trainers, we do not diagnose. However, we can assess the condition of our clients. We probably know their pain thresholds and normal physical conditions better than anyone.
With some injuries (dislocations, visibly or palpably broken bones, torn muscles), the choice is clear. It doesn’t take much experience to know that something is seriously wrong and that your client needs to see his doctor—or visit the emergency room—immediately.
But what about injuries that are not so obvious—such as sprains, strains and contusions? Such injuries can vary from slight stretching of a ligament and a superficial bruise to tearing of a ligament and deep-tissue damage. What do we do then? Persistent, acute or debilitating pain is a sign that the client needs to stop exercising that body part—if not stop exercising completely—and seek immediate medical care. We certainly do not want to cause additional harm to an injury.
I determine whether the discomfort is just excessive soreness—perhaps from delayed-onset muscle soreness (DOMS) or overtraining—and can be helped by stretching, massage and/or rest. A very gentle ROM test on the area can give me an idea. If the injury appears to be more serious, I stop immediately and refer the client to a medical professional. Even if I find out the discomfort is only from normal DOMS, I generally lay off that muscle group and find something else to focus on that day. None of my clients are competitive athletes who push themselves to the edge, so I find no need for their sessions ever to be unpleasant.
Hopefully the question of whether a client needs medical care is not one we need to ask often. Whenever there is any uncertainty, however, my motto is: “When in doubt, refer out.”
Jamie S. Dreyer
Owner, Further Fitness
New York, New York
I have all my new clients fill out a history and health questionnaire. I also ask my regular clients at the start of each session whether their health status has changed since I last saw them and how they are feeling that day. I always let clients know that I am a fitness instructor, not a healthcare professional, and that there may be circumstances under which I will refer them out for medical or therapeutic advice.
As a rule, when a client has been receiving medical care or physical therapy for an injury or surgery, I request clearance and input from the physician/chiropractor/
therapist as to the client’s current condition and limitations. If the client has not had treatment and/or says he has recovered, then I do a physical assessment. If the injured area comes up especially weak or I see a lot of compensation elsewhere in his kinetic chain, I may refer him for a medical evaluation before training.
Most of the instructors I train in Poolates™ tell me that their clients routinely ask them for [general] healthcare advice on topics like disease prevention. We have also found that quite a number of physicians and allied health professionals ask us for fitness information for themselves, and sometimes for their clients. I would love to see a greater number of health professionals learn more about fitness. My hope is that people in the health and fitness professions can start to work together more closely, so
we can offer our clients/their patients coordinated care.
Rebecca “Boo” Pfeiffer, JD, MPH
Owner, Poolates and Pfeiffer
When interviewing potential clients, I tell them that they will need to inform me prior to their session if they are in an acute stage of an injury. If this is something they are resistant to, they have
the option of finding another trainer. Whether or not I feel it is appropriate to train them depends on the type of injury they have sustained. If their joints (knees, shoulders, back) or muscles are in an acute state, owing to a fall or other activity, and they have not yet sought medical attention, I will not train them until they do. I insist on this. A minor sprain or strain to a wrist, hand, foot or digit is one thing; but an egregious injury is out of my scope of knowledge, and I will never train clients with such a condition. I allow clients to return to their sessions after they have presented me with written clearance from their physician, sports medicine doctor or PT.
One of my clients shattered her wrist in a hiking fall; she required surgery, and pins were placed in the joint. We consulted by e-mail and phone. She was still in shock from the injury, and I told her she could come back to train after her medical experts had cleared her. When she was released, her doctors prescribed certain physical limitations for her wrist, so we worked around those. I gave her a program that involved anabolic, breathing-based work while her wrist healed. She chafed at the bit constantly because she was worried about losing her fitness levels. Through reassurance from me and my attention to her answers to the many questions I had asked prior to our sessions together, she was able to maintain her fitness levels and heal at the same time.
If clients begin to complain of an insidious onset or chronic injury, I literally nag them into seeking professional help. I have no problem telling them that if they don’t, we will stop training until they do. I explain that it would be irresponsible of me to allow training to continue and that I would be opening myself to substantial liability if I did.
My clients and I work together in their pursuit of health. I coach them along to help them take personal responsibility for their bodies. I also walk the talk. If I have an injury, they don’t see me training! This tactic not only keeps me at low risk for being negligent but also allows my clients to realize that being smart is being healthy.
Nancy L. Jerominski
Owner, NLJ Fitness Consulting
When a client comes to you with an injury, first assess the entire situation. This means asking the following
questions: How did it happen? What activity was she involved in when it happened? Where is the pain located? How long has it been since it happened, and what, if anything, has the client done for it since then?
If it is a new injury, encourage the client to apply the R.I.C.E. approach, which includes the following:
- Rest—Stop any activity in that area that causes more pain, discomfort or swelling.
- Ice—Apply ice to the injured area for 20–30 minutes at a time.
- Compression—Wrap the injured area until the swelling ceases.
- Elevation—Raise the injured area, especially at night.
Follow these instructions for a 2-week period. If there is no change or the symptoms get worse, refer the client to medical care.
If the symptoms improve, then you can start training the client. Obviously, give special care to the injured area. Start slowly, making sure the area is appropriately warmed up. If it was injured in a specific sport, focus on gradually easing back into the movements of that sport. Use light resistance initially after injury, introducing exercises one at a time if they involve that area and assessing whether any of them irritate the injury. Always help the client stretch after the workout. Gentle stretches should be held for 30–60 seconds. After the first few workouts, ice can be used to protect the affected area, to reduce swelling and to speed up the healing process.
General Manager, Personal Trainer,
Group Exercise Coordinator
LifeStart @ RiverPark Athletic Club
When a client comes to me with an injury, I ask him a series of questions. Asking questions can help me discern whether, for example, the client is experiencing muscle soreness from working out or whether the injury might be something more. These are the questions I ask:
- Does the client know how he injured himself? In other words, did he fall, twist or pull a muscle while doing a particular activity?
- When did the injury occur? Yesterday? Last week? If the injury seemed to begin bothering the client just after our last session, I will review that session to see if we can identify what might have happened. This is why I always document my workouts!
- Does the area look or feel different from usual? Is there tenderness or pain?
- Did the client hear or feel a “pop” or other sensation or sound?
- How does the injured area impair the client’s ability to function?
If a nonemergency injury has just occurred, I will begin first aid and immediately refer the client to his doctor. When uncertain how to proceed with a pre-existing injury, I will give the client a Physician’s Consent to Exercise form for his doctor to fill out and return. This form is a protective measure for the client as well as for me. A trainer must never underestimate the potential for liability issues. The form asks the doctor to indicate whether or not the client can participate in exercise with or without limitations. The doctor may also indicate that the client is not cleared for exercise. I inform the client that the sooner he returns the form with the doctor’s consent to exercise, the sooner he can get started with his program.
As trainers, we must know the specific signs of injury that are common to our work and how to administer first aid if necessary. However, it is imperative that we also know our limitations and stay within the area of our expertise. It is always best to refer a client to his own physician for an examination, even if the injury appears to be mild. Often, an injury that appears to be “nothing” can be the beginning of a larger problem.
Owner, Germaine Fitness
Roseville Health & Wellness Center