I tend to work with some pretty jacked up people, and by jacked up I mean a lot of medical issues, injuries, scar tissue, restrictions, and you name it thrown in to the mix. Most of my clients are medical referrals, which means they pretty much all start out with individualized attention. I’m not going to sit here and say I’m smarter than anyone else because I work with these kinds of people or anything, far from it actually, but they do present some unique challenges that the average gym-goer doesn’t present, and as much as I like deadlifts and squats and screaming into a corner while listening to “I hate your face” music on my iPod, it’s probably not going to get to that level for some of my clients.

That being said, I still want all my clients to train like beasts, in any way they can.

To give you an idea, on any day I may have a knee replacement client pushing a 300 pound sled across out carpeted floor, have a hip replacement client rack pulling 2 times their body weight, rotator cuff rehab clients hauling 100-200 pounds per arm across the gym, disc herniation clients doing chinups with added weight, and ankle injury clients doing various types of pushups or hip bridges. The key is doing the right movements for the right reasons and with the right coaching.

One component I try to get any client to work on when recovering from injury is a consistent grooving of any desirable pattern, such as a hip hinge, squat, lunge, push, pull, rotation, or combination of movements like these. Pain is an interesting variable that causes the mind to subconsciously and consciously alter movement mechanics in an attempt to avoid perceived situations of threat, which means even if there is no hope in Kim Kardashian winning a spelling bee (“Hey Kim, spell Armenian.” “7.” Thanks for that.) that the movement in question would cause any injury, the person will still compensate away from using the injured area or areas, which makes for a compensation pattern and creates a whole host of new problems down the road.

Their high-threshold compensation strategy is all designed to help preserve and brace for the impending pain, which may never actually come.

Let’s use a simple example like a toe touch for someone with low back pain. If I were to test their hips and find they have fantastic hip mobility through every movement possible while laying on their back and being fully supported by the ground or table, then had them try to touch their toes only to find they started the movement from their spine instead of their hips and complained of tight hamstrings, I may think that they had to work on hip flexibility because they weren’t moving the right segments and would appear tight. This flexion-based compensation pattern would eventually lead to further tweaking the low back, and stretching the hamstrings would only result in me killing ten minutes without seeing any real benefit other than wasting my clients’ time, and probably destabilizing their supportive outer unit more and helping the problem become worse.

When someone is in pain, they approach new situations with a level of apprehension similar to the one I get when I hear there is going to be a spawn of Snooki roaming the earth stealing souls and creating bad reality television shows. This level of apprehension can alter their movement patterns, desire to complete the movement itself, and affect whether they feel more or less pain after the given movement. Top it off with the fact that pain can cause social withdrawal, depression & anxiety, and a whole host of other psychological manifestations, and you can understand why a lot of people will say that there is absolutely no way you should train in a painful state or use a painful movement.

From a study by  Crombez et al (2002) that showed the pre-movement perceived level of pain an individual currently experiencing pain would feel following the expected movement versus a repeated trial, people who catastrophize their pain tend to feel a lot more pain, regardless of the activity and regardless of the outcome.

The second time the individuals were put through the same movements, they felt less pain, and they felt less pain with successive attempts. This means that if you are throwing someone into a new workout program, start low and explain everything that is going on, what they should or shouldn’t feel, and what things to look out for. Then do it again and again until they feel comfortable with the fact that it isn’t causing any pain before ramping up the intensity.

One option I prefer to use is to use a systemic exercise or movement that requires very little out of the affected area. Take a rotator cuff irritation for example. The common mechanism of injury is movements where the humerus moves away from the body and the scapula doesn’t provide enough stability, causing the cuff to overwork and become damaged. This is a very simplified explanation, but you get the picture. Performing loaded carry type movements, like farmers walks, suitcase carries, etc can help train the entire body while keeping the humerus tight to the ribs, and also activating the muscles to prevent the shoulder from completely dislocating, making it a great alternative to typical rotator cuff training exercises.

Rotator cuff irritations also respond very well to pulling variations, specifically things like chinups. I’ve had guys fresh out of physio begin working on progressing into weighted chins with up to 25% of their body weight added to the lift prior to beginning any type of pressing work, and that seems to produce the best results compared to specific rotator cuff strengthening or any kind of dynamic stabilization work. Again, it’s not for everyone, but those who have the mobility and stability required to do chinups will no doubt be doing chinups.

When training someone with knee injuries, I prefer to use a sled push versus a squat or leg press, due to the fact that there is no loading during the eccentric phase, and the stability provided during the movement comes from 4 points of contact with the floor (both feet as well as arms) instead of two, meaning the knee doesn’t have to be the sole source of stability. The range of motion can also be as short or as long as possible, meaning they don’t feel impeded by not being able to “squat to parallel” like many people would say is optimal. Unfortunately, my clients awaiting knee replacement aren’t going to be able to physically squat to anything resembling parallel, especially with eccentric loading.

Another knee injury favorite is performing a step-back lunge variation instead of a step-forward lunge. The major difference between the two is that the step-forward lunge involves a lot of shear forces on the anterior structures of the knee (patellar tendon, quadriceps tendon) as the foot hits the ground and the tibia becomes stationary while the femur continues to want to travel forward due to momentum and body weight. A stepback lunge removes this shear force, and allows the hip to stabilize throughout the movement, again reducing the negative forces the knee is exposed to.

For spinal issues, most people don’t have the necessary flexibility to get into a conventional deadlift approach, and will invariably flex their spine to make up the range of motion. This is a common compensation due to the prime movers (glutes) trying to pick up the slack of the spine and provide some type of stabilization, but this is a poor compensation pattern and will eventually result in overuse of the low back.

To combat this, I get people to engage in more movements that require them to have a vertical spinal posture without hip flexion to begin with, and eventually work into small amounts of hip flexion as long as they can maintain a neutral spine. Mike Reinhold had a great component on his and Eric Cressey’s Functional Stability Training where he outlines one of the big cues he uses with a lot of his patients: “Neutral, brace, breathe.” This makes the person always aware of getting to neutral and not compensating, forces them to engage their core to act as a protective shield, and makes them not hold their breath through the movements, which can de-stabilize the core.

Sled pushes and pulls work really well here as well, depending on how high or low their grip placement can be. I’d love to get a Prowler to push around the gym due to the elevated handles.

The fact that these are seldom considered directed types of exercises for the person’s specific injuries is kind of the point. By not making an exercise one that’s specifically targeted to work the VMO during knee pain while simultaneously working the leg in a different direction than it’s used to while limiting risky forces can help make a rehab program more effective, and also remove the psychological hindrance the person may feel towards a specific exercise, thinking that there may be the potential for pain involved. Once they get their feet wet with the movement and realize there is no pain, or discover acceptable coping mechanisms to own the movement and not create a negative compensation pattern, they can push the intensity into new and beneficial realms, while still working on improving their functional outcomes and limiting the chance of any physical or psychological harm.

That, and watching someone recovering from a total knee replacement push a 300 pound sled across the gym floor with a crowd of supporters screaming encouragement at him helps everyone out in the end.

Regardless of what hurts, you CAN in fact train like a complete animal in the gym, and by making small adjustments in your approach, you can see better results not just in functional improvements but also in outlook, demeanor, swagger if you will, and overall confidence in what is possible than by sticking in a strictly rehab mindset. Granted, some people will need to have more coaching to get to this stage, and some may never really reach this level if they are high catastrophizers. The end goal should always be having the person walk out of the facility (if they could walk in that is) with their head held high and feeling like a million bucks, and like they had a productive workout that proved they have mastery over their limitations, and not the other way around. If they start strutting on out there like the Nature Boy, I’m a happy camper.