I have a potential client who I have not met with yet. I will be doing a consultation with her early next week. She was attending another facility when she hurt herself, and now she wants to train here. On the hip ab and adduction machines, she somehow managed to hurt her calf (not too sure which leg yet), and it resulted in major swelling and pain in the calf. I'm having a hard time isolating the cause of this and was wondering if I should be focusing more on the joint or the muscles to search for the cause.
Know your role. There are several key questions that need to be answered first before properly helping this client. With not much background to go on, I am assuming you are a personal trainer. If so, the best way you can immediately start helping this client is to know and understand your role in the process as it relates to her and her injury. Ethically, my opinion is that as a personal trainer, diagnosis is outside your scope of practice. Therefore, the first and best way you can help this client is to take control of the situation by referring her out to a qualified physiotherapist or CAT who can properly test, assess and diagnose her condition.
I know. I know. Any passionate personal trainer is dying to jump into the process and take a much more active role in client problem solving than simply referring out and going back to the gym to count more reps. Well, the good news is, there are two specific ways you can help. You can perform an (1) initial assessment to create a general yet practical blueprint for the physio that could help him/her to put the pieces together more efficiently or (2) you can also request to be part of any post treatment/preventative/corrective/functional protocol that will be needed to recondition and reeducate the client.
If she has injured herself and is in the acute phase of trauma, your best bet is to confirm that all of the SHARP principals are present (swelling, heat, altered function, restricted movement and pain.). Don’t make assumptions based on second-hand information, even with these most basic details. By the time she reaches you, if it is after 72 hours, cold can be replaced by heat application to reduce swelling and/or pain.
When you do your initial consultation with this client, I would advise first completing a detailed health history report on the new client that not only includes questions regarding the history, mechanism of injury and short-term events leading up to the injury, but also ask questions that can paint an accurate picture of any long-term factors that could possibly have led to the specific calf/lower leg issue. I am not going to outline an entire assessment protocol, but there are a few things that must be included: a bilateral comparison to gauge the degree of swelling, questions regarding the location and sensation of pain, questions regarding the mechanism of injury (i.e., when the pain started and what movement(s) triggered it).
Any lower extremity ROM, strength tests, gait analysis or postural assessment tests may be influenced by the injury and resulting inflammatory response. As a result, they could be less predictive of the initial cause and therefore can be omitted for now. It is very important that you DO NOT do manual testing on the ankle or knee. This needs to be done by a qualified health practitioner.
Joint or Muscles?
By joint, I assume you are referring to the articulation of the talus and tibia/fibula, and by muscle, I will assume you are including tendons as important associated structures. Remember, there are approx 33 joints in the foot and ankle and over 100 muscles, tendons and ligaments. This can make it more difficult to determine the type of structure and exact location of injury than if we were looking at another joint like the knee for example.
There are however a few things that are known about ligaments at the ankle joint. First, the most often torn ligament in ankle sprains is the anterior talo-fibular ligament (ATFL). Secondly, the deltoid (3) ligament is on the medial side of the ankle/foot and is far stronger and less susceptible to sprain. A correlate to this is that the more likely mechanism of injury if it is a sprain would be inversion at the ankle. The third point is that ankle sprains without proper rehabilitation are far more likely to reoccur.
As far as tendon and muscular issues, if she was using the adductor/abductor machines when she hurt herself, you need to find out if she did it during resisted abduction or adduction.
The first and most likely reason for ankle pain on the adductor/abductor machine would be a combination of excessive loading and faulty mechanics. Too much resistance is usually the cause of compensation, and in this case, it could have caused her to initiate movement from her feet instead of her hip. Add an unstable ankle to the equation, and you could have an inversion sprain or other trauma. Ask her about past ankle sprains and if she used physiotherapy to rehab them or let them heal on their own.
Another possible hypothesis is that she experienced a bout of acute exertional compartment syndrome that was due to unaccustomed exertion and caused an increase in hydrostatic pressure and potential vascular compromise. I would ask her if she used the adductor/abductor machine regularly or if it was a relatively new addition to her program. There have been reports of this occurring at various levels of intensity, and therefore it shouldn’t be prematurely ruled out. If this is the case, her pain will worsen not subside, and it can become completely disproportionate to the degree of injury.
Finally, the best thing you can do after this problem is resolved is to get her away from using the adductor/abductor machine. Offer her a variety of more functional alternatives that will place no load on the ankle joint even if compensation does occur. I know she’ll love you for it!