New client problem... Urgent help needed!

[Jean-Paul]

I start a new client today who is pretty fucked up to say the least. He is scheduled to do a full right hip replacement next Monday, and in a few months he has to have his right shoulder operated on. Here's the situation.

He's been training with a bodybuilder trainer for 5 years. 'Nuff said. The guy has him "pushing through the pain" on many exercises, including leg presses and other heavy bilateral leg movements. He is taking a week off after his surgery, and then wants to get right back on is program. I don't think he knows what he's in for.

He is not actually giving up the other trainer (yet--I need to work on him a bit). The other trainer is a bit of a head case. People who get injured or sick do so because "they are weak" and all problems are self-inflicted from a lack of self discipline. To his credit, he is in his mid 40's and he has never had a major injury and is rarely if ever sick. He doesn't have much of a life outside of bodybuilding, and I'm not sure how he hasn't burned out yet. He is so strict on his clients I don't see how they can even stick with him. He dumps them or gives them a verbal lashing if they slack on their diets or miss workouts.

He looks like a bohemian gladiator or something. He's 6'4", probably around 5% bodyfat and 235 or higher, and wild long hair. He would look much more comfortable wielding a 50 pound broadsword, with which he would probably be quite natural. In my opinion though, he is solely responsible for my new client's hip and shoulder problems. They have just gotten progressively worse, and the best this trainer can do is rev up the rhetoric, taking no responsibility of course. He has been a trainer for 25 years, but has never been certified. He's just a local "guru" (in every negative sense of the word), who is convinced that he is the only source of knowledge in the training world.

My client fractured his hip playing baseball abour 15 years ago, and trained through it instead of letting it heal. He is driven like few people you will ever meet, and based on my initial assessment, has a pain tolerance that is off the scale. Although he can barely walk though due to the pain, but I'm not sure he needs the surgery.

His piriformis is so short that I could not internally or externally rotate his femor even 5 degrees. He obviously also has complete GM and TFL restriction. I don't think he really has any tears, and his bone is not going necrotic from being broken, yet the surgeon is going to go in and saw off the top of his hip and give him a titanium ball and new titanium socket.

I did a quick piriformis and GM release on him and although the increase in ROM was negligible, it significantly decreased his pain. What I REALLY need is to send him up to Bill for a week. Money isn't a problem for this guy, but I am coming in really late in the game, and I'm afraid that if he doesn't actually need to have this surgery, he is only going to guarantee chronic hip pain for the rest of his life.

I don't know if I should talk him into putting off the surgery for a month or if I should just let him proceed and keep my mouth shut. After all, I'm not a doctor. But no one in this area specializes in soft tissue injuries. His past PTs have all just followed the book; ultrasound and some hip mobility stuff on a machine, and eventually they just gave up on him. He has layers upon layers of scar tissue in the hip, but my nagging intuition (which could be wrong) tells me that it is fixable without surgery.

I am seriously considering convincing him to go to Indy for a week if I can convince him. I think my first session with him yesterday may have convinced him that there are other options.

Moving on to his shoulder... He told me that he does have a confirmed tear to his infraspinatus and his labrum. He does a ton of chin-ups, rows and curls (his trainer LOVES preacher curls). Dips are murder for him, so he tries to avoid them, so he does a ton of tri pushdowns. I haven't done any assessments on his upper body mobility yet. If he has image-confirmed tears then I would think that curls (although he reports that they don't hurt him at all) would be ill-advised. For that matter, if his infraspinatus is actually torn, I would imagine that his teres minor is probably not normal either, so a lot of heavy tri work would also be ill advised.

In closing, this guy wants to maintain his shape desperately, but I don't think he should be training at all. I think he needs to just do mobility work and ART for as long as it takes to get some return to normal, pain free movement. Maybe he should do his shoulder first instead of his hip, if indeed his shoulder is confirmed as torn.

Any advice at this point will do. I see him today at 2:15pm CST, so if you can take the time to advise me before then it is all the more appreciated.

[Ian Kay]

I have a friend, a neuro-muscular therapist, who has dealt with many people over the years that were headed towards surgery, and after 3-4 sessions with him, cancelled the surgery and proceeded to live their lives, pain-free. I witnessed one very recently. The woman asked me about several stretches, told me about some sort of disc condition, told me about the surgery. The way she described the pain reminded me of things my friend had spoken about. I sent her to him, and he fixed her up. No surgery. No more pain. Definitely set something up with Bill, if at all possible! How would it not be worth a try?

As for continuing with the other trainer, it depends on how stubborn this guy really is. If it was me, I'd tell him that his recovery time should be with you, because the other guy specializes in hardcore muscle-gains, not rehab. Over the time he works with you in "rehab", drop all sorts of info on form, injury prevention, proper progression and proper exercises. Several months in, he may realize what good gains he's making without the Viking warrior... and without the pain.

Don't know if that helps at all.

p.s. When you mentioned the torn infraspinatus and labrum, and that he "tries" to avoid dips... I shivered. I have shoulder issues (always have) without any tears, and man, dips hurt me! (I haven't done a dip in probably a year and a half now.) I can't imagine attempting them with tears!

[Lisa~]

I agree to encourage him (press him even) to see Bill before his surgery date to see if he might have a real non-surgical option. Other decisions can be made after his session with Bill.

[Bill Hartman]

While I appreciate the confidence, there's a lot things that are not known.

His lack of mobility may be joint related and the soft tissues simply adapted. That's not to say that some ART or whatever won't help but if the joint is shot, it's shot.

You also can't place all the blame on the trainer. The guy didn't let his hip heal correctly. That's his fault. Continuing with the trainer while experiencing progressive injuries. That's his fault too. Caveat Emptor.

We also don't know the true condition of the shoulder and to what degree function is affected. Some labrum injuries and cuff tears can be rehabbed, some can't.

You need to track down the docs involved and/or get the medical notes to see where this guy is in regards to severity and types of injuries and why they are moving forward with surgery.

Regardless, try to restore as much mobility and strength as you can prior to surgery. the better he goes in, the better he comes out.

Bill

[UConnJulie]

JP, read your post on my way out the door, and come back to reply only to find that Bill wrote what I was going to say.

If the guy's hip is down to bone on bone, no amount of soft tissue work will restore his joint ... and depending upon where the previous break was and how it healed, much of his limited mobility could be due to that. He will benefit greatly from whatever mobilty work and soft tissue stuff you can provide before surgery, and hopefully after surgery he can find a PT who will continue to address this.

If I were you I would work on educating this guy about letting the body heal and working through the pain is not some proof of manhood. Sounds like the other "trainer" (I shudder to even use that word!) is someone he should avoid in the future.

How old is this gentleman? Just curious ...

[Jean-Paul]

He is in his mid forties...

I agree that he let it heal improperly, but I do think that a trainer has an obligation to do what is in the best interest of the client, and clients can't always be accountable for proper program design if they trust a supposed expert. That trainer's ego is just huge, and he pushed a guy who doesn't know how to listen to his own body all the way to his breaking point (literally).

I do think that he is probably bone to bone. The problem I foresee then is when he is recovering from surgery. I am probably not going to even touch him till he's done with PT (even though he wants to start right back up). But when he does return, the problems his hip has will only come back because his muscles that control flexion, extension and rotation are so tight that he jump into that fire from the frying pan.

I'll try to get some more information today.

[russ]

I'll second what some others have already said and add that the criteria for hip replacement all relatively strict (I'll assume that his surgeon isn't going soft on the criteria). His arthritis should be sufficiently advanced that there really aren't any other options.

As for the other trainer, invite him over and we'll slap him around at Wii golf. That should take him down a notch :p

[UConnJulie]

Originally Posted by Jean-Paul

He is in his mid forties...

I agree that he let it heal improperly, but I do think that a trainer has an obligation to do what is in the best interest of the client, and clients can't always be accountable for proper program design if they trust a supposed expert. That trainer's ego is just huge, and he pushed a guy who doesn't know how to listen to his own body all the way to his breaking point (literally).

I do think that he is probably bone to bone. The problem I foresee then is when he is recovering from surgery. I am probably not going to even touch him till he's done with PT (even though he wants to start right back up). But when he does return, the problems his hip has will only come back because his muscles that control flexion, extension and rotation are so tight that he jump into that fire from the frying pan.

I'll try to get some more information today.

So, pretty young for THA ... I agree with Russ that the criteria are pretty rigid ... especially for the "very young"!

I do agree that his muscular/soft tissue limitations will be worse after surgery, especially because he will be limited in what movements he can do. Around here (Greater Hartford, CT) surgeons vary what they say with respect to hip precautions ... some say to abide by them for 6 weeks, some 3 months, some 6 months ... and some for life. Not only does it vary from surgeon to surgeon, but also patient to patient from the same surgeon. Although I will say that I see more "6 weeks" now than in past years.

What this means is that although there will be certain positions after surgery that he will not be "allowed" to do (flex hip beyond 90 degrees, adduct beyond midline, and internal rotation of any kind), he will benefit greatly from any soft tissue work that you can do prior to surgery.

Having watched several surgeries though, the surgeons put the patient through a pretty rigorous range of motion test ... so the good news will be that the joint and muscles are capable of greater ROM than he will likely have unsedated. The key will be retraining his muscles to restore proper mobility and reduce excess tension.

I also agree with your statement about the other trainer at least being partially responsible as he is a "professional" dispensing advice ... the consumer has no real way to know that the advice he is receiving is incorrect or in this case harmful. Too bad there is no state board you could report him to ...

Keep us posted on how he's doing ...

[bryanc]

I think that after his replacement and immobilization, as well as his rehab, you will have an almost completely different client on your hands, JP. Any assessment you do pre-op would be purely out of interest and to have a "pre-op baseline"; but this guy is going to go through the orthopaedic wringer (i.e. he's gonna be kinda f*cked up). The immobilization period alone will cause atrophic and strength changes. I'd leave him alone until the surgeon (and subsequent health practioners) are done with him.

[Jean-Paul]

Thanks Bryan. I plan to do just that. I don't think he really knows what he's in for with this one, so scheduling a session 1 week after surgery is obviously not realistic, but telling him that didn't sway him, much like the words of the slave who whispered into Caesar's ear, "Thou art mortal," fell on deaf ears. I think the gravity of his situation will be pretty obvious, and don't count on seeing him until he's cleared rehab.

[tonymcclellan]

Does this big old trainer work at your gym? How do you have experience with him?

[sixpackinacooler]

Rob Tillman, he can fix anything.

[Sign]

So how did things go with the client? Did he have the surgery and was it successful? Is he still in rehab or have you begun working with him?