After an apparent workout injury, telling a client to "push through it" is not a trainer's wisest course of action.

It began, in late 2000, with a routine personal-trainer consultation. Alvin Howard, who was then a running back on the Greenville College football team, had recently suffered an ankle injury and wanted to improve his football skills. Howard paid a visit to Missouri Bone and Joint Center Inc., an orthopedic and physical training clinic in St. Louis. Kevin Templin, a certified athletic trainer employed by MBJC, provided Howard with an initial evaluation, which consisted of an interview, measurements and some performance testing.

Templin asked Howard to estimate the maximum amount of weight Howard could lift while performing certain exercises, including bench presses and squat lifts. Significantly, however, Howard did not perform any actual squat lifts, although this was normally part of an MBJC evaluation. As Templin testified later, he simply ran out of time. In addition, Templin failed to ask Howard when he had last exercised. Because of his ankle injury, Howard had not done any lower-body workouts during the previous 12 weeks. At trial, Templin admitted that this would have been important information to consider when designing Howard's workouts.

During Howard's second training session with Templin, in January 2001, he felt a pop and a sharp pain in his lower back while doing a set of squat lifts. Howard immediately informed Templin, who responded, "No pain, no gain." Told to "push through it," Howard was able to finish the set, during which his pain increased significantly. Following Howard's completion of the set, and at Templin's instruction, Howard did some stretching and rode a stationary bike, neither of which relieved his pain.

Howard was diagnosed with a herniated disc, which necessitated surgery. Four years passed and, his back repaired, Howard sued MBJC, alleging that it was negligent in three respects: 1) failing to conduct a proper physical evaluation before designing a workout program; 2) instructing Howard to continue working out after being advised of his back pain, thereby increasing his risk of injury; and 3) refusing to discontinue Howard's workout, thereby failing to provide proper medical care.

At the close of evidence, MBJC moved for summary judgment, which the trial court denied. The jury found MBJC negligent for all three acts and returned a verdict for Howard in the amount of $175,000.

On appeal to the United States Court of Appeals for the Eighth Circuit, MBJC filed a renewed motion for judgment or, in the alternative, a new trial. MBJC argued that Howard failed to show that the clinic did not conduct a proper evaluation. In addition, the clinic claimed that Howard failed to present evidence that Templin's workout instructions were causally related to Howard's injury. The evidence presented at trial, MBJC argued, only established that Howard suffered a herniated disc during his workout, not that he was injured by continuing to work out.

In Alvin Howard v. Missouri Bone and Joint Center [2010 U.S. App. LEXIS 16699], the Eighth Circuit held that under Missouri law, to establish a claim for negligence, Howard must prove three principal elements: 1) the existence of a duty on the part of MBJC to protect him from injury; 2) a failure of MBJC to perform that duty; and 3) an injury proximately caused by MBJC's failure. In addition, the court noted that absolute certainty was not required to prove a causal connection between MBJC's actions and Howard's injury. All that was necessary, the court held, was evidence showing that the injury was a natural and probable consequence of MBJC's actions.

In ruling that Howard presented sufficient causal evidence for the issue to go to a jury, the court noted that Howard felt a pop or pull in his back while lifting, and that this pain increased significantly between when he felt the injury and when he finished the set of squat lifts. In addition, the court noted that while Howard's pain began during his workout, the tingling and numbing sensation in his leg and foot, symptoms consistent with a herniated disc, did not begin until after he finished the workout. When taken together, the court ruled that the evidence was sufficient to show a causal connection between MBJC's actions and Howard's injury. As such, the question of causation was properly presented to the jury, and the district court did not err in denying MBJC's motion for summary judgment.

As for Templin's actions prior to the injury, the court, citing MBJC's own expert witness, found that the standard of care applicable to certified athletic trainers generally should have included testing Howard's ability to do squat lifts and asking Howard when he had last lifted weights. Both acts, the court ruled, would have been vital in developing a proper workout plan and easing Howard into a workout schedule. With MBJC failing to perform these basic acts, the court ruled, the evidence was sufficient to allow a reasonable jury to find that Templin breached the standard of care of certified athletic trainers. In addition, the court found that Templin's actions immediately after being advised of the injury constituted a violation of the standard of care.

Finally, MBJC argued that even if Templin did breach the standard of care, Howard presented no evidence that this breach was causally connected to his injury. MBJC argued that Howard should have to show: 1) what a proper evaluation would have revealed; 2) what workout plan would have resulted from such an evaluation; and 3) that had Howard been using this workout plan, he would not have been injured. MBJC's argument, in essence, was that there was no evidence that a proper evaluation would have saved Howard from injury.

In rejecting this claim, the court held that while no one could say for certain that Howard would not have been injured had he been properly evaluated, absolute certainty is not required to prove a causal connection between MBJC's actions and Howard's injury. The evidence, the court ruled, leads to the logical conclusion that if certain things had been properly done, certain results would not have occurred, and since such results did occur, it was proper to submit the case to the jury.

So what does the Eighth Circuit Court's decision in Howard tell fitness center owners and certified athletic trainers? First, it should send a clear message to all trainers that they cannot take shortcuts or fail to perform a full and proper evaluation of new clients. Besides making it impossible to develop a proper workout plan, it also increases the risk of injury to the client and the facility's legal exposure. Second, because of their presumed expertise, certified athletic trainers are going to be held to a higher standard of care, especially when working with athletes or clients trying to rehab from an injury. Therefore, they need to follow all proper procedures.

Finally, when a client informs a trainer that he or she is in pain, telling him or her to "push through it" is not the wisest course of action. All certified athletic trainers should take a moment and determine the seriousness of the injury. If Templin had done so, it might have saved MBJC $175,000.

Legal Action

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