Injury & Rehab:
are you asking the right questions?
Over the past 20 years I have seen incredible progress in the training of health and fitness professionals. The modern fitness professional now undergoes rigorous training in anatomy, physiology, correct lifting techniques, program design and injury prevention strategies.
However, despite this improved level and quality of training, I still hear about new gym members having to suspend their memberships due to an injury that was directly caused by their new exercise program.
How can this be the case when our training programs have improved so much? I believe the answer lies in the trainer's over-enthusiastic focus on the actual exercise program and technique, combined with a failure to properly pre-screen the new client for injury risk prior to prescribing and starting the actual program.
Many trainers simply don't appreciate the importance of a thorough pre-exercise screening and a comprehensive analysis of the client's past injury and exercise history.
It should be mandatory for all health and fitness professionals to perform a comprehensive subjective and objective assessment on all new members and clients – otherwise injury risk is increased and everybody loses. At the very minimum, all new members and clients need to complete a full pre-exercise questionnaire – with special attention paid to the following areas:
Past injuries – One of the biggest predictors of future injury is a past injury. If a client mentions on their pre-exercise form that they had a past knee injury, the trainer is obligated to delve deeper to determine the real risk of re-injury.
A major mistake for health and fitness professionals is making the assumption that because an injury happened many years ago it no longer contributes to the client's injury risk. Be aware that any past injury – regardless of the time that has passed – may still reduce joint range and impede muscle function.
Past fractures – The risk of injury is greatly increased if the client has previously suffered a fracture, especially if it involved a joint and was treated with some form of immobilisation, i.e. plaster bracing or slings.
Health and fitness professionals often fail to recognise that many joints that suffer injuries, regardless of the time that has passed, never regain full range of motion. This is especially true for many ankle fractures and even some severe sprains.
An ankle fracture from 20 years ago that required even a small amount of time in plaster can still produce a reduction in ankle dorsi flexion on the injured side, leading to excessive subtalar joint pronation on the injured side – and increased injury risk with exercise.
Special note: trainers should be especially aware of old clavicle fractures in their client's pre-exercise screening. These injuries can greatly impact scapulohumeral, acromioclavicular, glenohumeral and sternoclavicular joint range – and can greatly impact the injury risk for new exercisers.
Imagine a client with a shorter clavicle on one side performing an exercise such as a Machine Bench Press. The machine system places the joints under different stresses due to the clavicle length imbalance, which can lead to shoulder problems as the program progresses.
I always advise clients with past clavicle and AC joint issues to exercise using single cable or dumbbell variations, as opposed to two-arm machine-based exercises. The cables and dumbbell variations allow each shoulder to work through a range and plane that reduces the stress on the joints themselves, and lessens injury risk with exercise.
Exercise history – All new clients need to be asked about their exercise history and whether they experienced any injuries, pains or problems as a result of previous exercise regimes.
A common story is the new member that joined a gym five to 10 years ago, only to drop out after six months due to 'sore knees' caused by treadmill running or step classes.
This information should sound a warning bell for the trainer to look more closely at quadriceps function, muscle bulk and ankle range of motion – right versus left – before commencing the exercise program itself.
Other medical conditions – Trainers need to know about the current state of the client's general health. There is no question that general fatigue, poor sleeping habits, as well as cold- and flu-like symptoms, will severely reduce the recovery capacity of the new client.
Armed with this knowledge, the trainer will be sensitive to the client's exercise tolerance and be able to modify the initial training load to ensure that the risk of a fatigue-related injury is reduced.
Joint range and instability – While all new clients should undergo a full joint range of motion assessment in the physical component of the pre-screening process, many joint range issues can be uncovered through effective questioning and careful listening.
The unstable or hyper-mobile client may talk about their joints 'clicking' and 'clunking' or feelings of their joints 'giving way', and may even mention that they are 'double jointed'. Again, these comments are warning signs that the client is at risk of an exercise-related overuse injury.
Trainers need to follow-up these comments, match the history to the physical examination, and create a structured exercise program taking these findings into account. I always recommend that hypermobile clients use the 'short lever' principle when selecting appropriate exercises. 'Short lever' exercises involve the load being kept close to the client's centre of gravity, thereby reducing the distance of the lever arms involved, e.g. performing close grip bench press over wide grip variations and close grip pulldowns over wide pulldowns.
Past sporting activities – It is always a good idea to delve into the client's past sporting activities, as this information can lead to the discovery of some useful injury prediction material. Some common issues for sporting populations may be the increased incidence of back instability in mobile gymnasts and dancers, shoulder issues in swimmers (also ask if they are bilateral breathers, as it is common for single sided breathing patterns to produce reduced range of cervical and thoracic rotation on the non-breathing side), and thoracic spine stiffness issues in cyclists.
A final word on gender issues – sorry boys!
Be aware that the majority of males are very reluctant to share their medical history with anyone – perhaps because they view it as a sign of weakness, or simply because most males don't pay a lot of attention to the finer details and just forget about what happened in the past.
It is vital for health professionals to probe especially thoroughly into the medical history of new male clients, because it is not uncommon for a male client to neglect to mention any past injuries when asked – only to reveal multiple surgical scars on his knee when he stands up, and then say 'Oh I forgot about the knee reconstruction I had a few years ago – I didn't think it was important'.
Improved levels of education and undergraduate study in the area of exercise prescription has come a long way in the past twenty years – however we must not lose touch with the basics of safe exercise prescription and the performance of comprehensive pre-exercise analysis.
|Photo 1. One arm cable chest press
Single arm variations such as one arm cable presses allow each shoulder complex to work in a range and position that is independent of the opposite side – especially important in clients with past shoulder injuries and old fractures.
|Photo 2. Reduced dorsi flexion
Many ankles do not regain full dorsi flexion following ankle fractures, sprains and immobilisations – always compare left to right joint range in your pre-exercise examination.
Paul Wright, BAppSc (Physio), Dip Ed (Phys Ed)
Paul is one of Australia's best known and respected health and fitness educators, having been directly involved in fitness leader education for more than 20 years. Paul has recently launched an online delivery portal for health professionals that incorporates more than 60 hours of intensive injury prevention and rehabilitation sessions, including a dedicated training pathway for personal trainers.
Special Offer for Network members: you can find out more about Paul's new program and register for free resources by going to www.PaulWrightSentMe.com