One of the things I love most about training is the constant challenge to learn about the people I’m working with. I mean, I loves me some deadlifts just as much as the next guy, and when I can take Little Mary Sunshine and get her crushing her body weight and feeling like she’s going to rip someone’s face off just to stave off the intensity, it warms my heart. Another wicked awesome fun time is when Johnny Beergut decides to take control of his life and skip on thirds of dessert, then starts breaking down into soft weeping when he finds out he lost 25 pounds this month. Good times, man. Good times.

These are the easy things about training, the kind of things that pretty much any trainer willing to invest time and energy into helping their clients achieve their goals can get. What makes training a challenge is when you get someone who walks through the door that makes you almost want to throw your hands in the air and walk in the other direction.

So I’ve written in the past about a lot of different specific things, like shoulder problems, back problems, knee problems, etc. Considering the fact that the vast majority of my clientele are injured or recovering from injury, I figured I would write about what I know. However, there are always situations where the average is not the case, and you have a few outliers who come through the door and make you scratch your head and think to yourself “What the hell am I gonna do with this guy?”

Unfortunately, not everyone who presents with subacromial impingement will have some form of scapular dysfunction, just like some people with torn ACLs won’t have any trauma to the actual joint capsule or other ligaments, which means you can work them differently than the rulebook says.

On the other hand, there are those people who come in way worse than they should be, and have multiple conflicting problems that make working one specific area almost impossible. We’ve now shifted from the extreme right of the bell curve to the extreme left.

Unfortunately, we can’t really learn about how to work with specific areas of the body without generalizing the hell out of the approach, which means those outliers at either end of the spectrum get left out in the cold and our ability to apply what we know about a specific condition gets stretched when we have someone in front of us who doesn’t “fit the textbook.”

Let’s take an example of two clients who have recently had hip replacements. One is in their 70’s, and has had imaging that shows degeneration to the joints over the course of the past 25 years. They had the hip replaced when they couldn’t walk up stairs anymore. The other is a reasonably fit individual in their 40’s who actively plays hockey, runs recreationally and can drop into a full squat like no one’s business, but was in a car accident that resulted in a compound fracture to the femur and pelvis, which resulted in a hip replacement. Same doctor, same prosthesis, same recovery. Should they both be on the same program for follow-up? Absolutely not!!

Now imagine designing a program for someone with conflicting issues, multiple sites of dysfunction, and a few medical complications to go along with it. Take for example another one of my clients. I’ll leave his name out but give you a run-down on some of the things he has to deal with:

total knee replacement on both knees, the most recent in 2008

Stage 3 disc degeneration in 7 sites, stage 2 degeneration in 4 sites, fused vertebrae at L3-4 and L5-S1.

Flexion posture that cannot enter extension due to the degeneration

Calcification of left AC joint, rotator cuff fraying

OA in wrist, with fusal of three metacarpal bones

history of heart problems, high blood pressure and high cholesterol

pre-diabetic

Because of all this, he has limitations in a lot of movements, as well as consistent pain in his back and shoulder. Getting up and down on the floor is almost impossible. Using any unstable surface is pretty much a no-go due to the lack of proprioception throughout the injured or replaced areas.

So my question would then be a simple one: Where would you start?

I asked this question to a room full of professionals at a conference I spoke at last year, and got the return answer of simply ………………………… silence.

This was a room that was full of personal trainers and strength coaches, not to mention a few physios, chiropractors, and a smattering of community health nurses. No one wanted to venture a guess, because they all knew they would be wrong.

And that’s okay.

The moral of this little exercise is that there is no one perfect program. Every now and then you have to use your best judgement, and simply throw shit at a wall until you find out what sticks and what doesn’t In the case of this client, we had to go through a short trial and error phase to find out what movements he could do, and which ones caused pain or discomfort before figuring out a sound program that worked well for him. It was definitely not a cookie-cutter program from a textbook, because he definitely isn’t a cookie-cutter client straight outta the text book.

Can he squat? Sort of. We’ll do the best squats he can possibly do.

Can he lunge? Sort of. We’ll do the best lunges he can possibly do.

Can he do pressing movements. Some, but only with the arm lower than the shoulder.

Can he do pulling movements? Always!!

Can he do spinal stability work? Limited, but yes.

Can he do mobilizations? Limited to certain joints, but some cause pain.

Can we do circuit training? If the intensity gets too high he gets dizzy and complains of chest pain, so we have to monitor intensity.

Will his exercises have perfect form or technique. No, but they’ll be the perfect technique that he’s able to do within his scope of capabilities.

The goal of technical perfection is a great one to shoot for, and means people will see the best results possible. However, when perfection isn’t possible, we have to accept acceptable. In the meantime, he’s still training hard, working up a sweat, and chasing golf balls all over the place. He’s enjoying the workouts, feels they are working him sufficiently and making progress, and that’s all that really matters. By throwing out the rule book and following a new set of rules (Above all else, cause no pain; work within limitations; keep him healthy and happy), we can do something truly remarkable as trainers and have a hugely positive impact on someone’s life.

So let’s hear from you!! Let me know a time in life when you were a complete ass-hat and decided the rulebook wasn’t good enough for you and you decided to do something different and it still worked out well for you.