“Doc, it hurts when I do this.”

“Then don’t do it. That’ll be $20.”

Sure, it’s an old joke. But it’s also smart advice for a trainer. The older your clients, the more often you’ll need to remember it: If a movement causes pain, the best thing is to avoid it.

But what do you do when a client tells you something like this: “My knees bug me, so I can’t do squats. Or lunges. Or leg presses. Or walk on the treadmill. Or really anything, I guess.”

Where do you go from there? After all, you signed up for this gig to impact people’s lives. And at a time when a fifth of Americans suffer from chronic pain, you’re going to get plenty of opportunities with clients like these.

For every painful exercise, there’s a painless alternative. I always tell my clients that unless they’re in a body cast, we can train around any injury. So far, that’s turned out to be true.

But before I share tips for working with clients who have the most common sources of pain I encounter—carpal tunnel syndrome, low-back pain, arthritis in the knees and/or hips, hernia—I need to start with a big caveat:

You’re a personal trainer, not a physical therapist. It’s not your job to treat these conditions. Seriously, don’t even try. If your client’s pain level happens to improve, great! But that’s not the main goal.

People with chronic pain typically spend a lot of time focused on what they can’t do. When they hire you, it’s your job to help them figure out what they can do.

These are the exercises that work best for my clients.

READ ALSO: “Don’t Let Your Clients Butcher These Three Exercises”

Carpal tunnel syndrome

Look at your hand, palm side up. That narrow “tunnel” where your wrist meets your hand has a lot going on, with bones, ligaments, and tendons all passing through. It also houses the median nerve, which provides feeling to your thumb and some of your fingers. Any thickening or swelling in that area (from trauma, injury, or arthritis) can squeeze the median nerve, causing discomfort in the thumb and first two fingers.

That’s carpal tunnel syndrome, which affects 3 to 6 percent of all adults. Because it weakens the grip, it makes exercises like rows, pulldowns, pull-ups, and curls a challenge. Some research suggests that exercise and fat loss may help ease symptoms.

I’ve had success using these modifications.

1. Loosen up

No need to grab every bar in the gym with a Vulcan death grip. I’ve seen clients safely—and painlessly—perform curls, pushdowns, and pulldowns simply by loosening their grip. Yes, you may have to lower the weight, but it’s better than nothing.

And use common sense: Never suggest a loose grip on, say, a bench press where the bar is over your client’s face. Avoid any moves where the weight might slip free and injure somebody.

2. If you can’t grip it, “hook” it

For lat pulldowns and seated rows, sometimes just hooking the fingers around the bar or handle can be a workable alternative.

By this I mean you’re just using the fingers (not the thumb) to hang on. The curve of the fingers will be the only thing that touches. (It looks kind of like the hand of a rock climber hanging from a ledge.) For some reason, my clients rarely report pain when using a grip like this.

Again, you may have to lower the weight. And again, be smart: Don’t use this grip on a pull-up or chin-up or anything where a slip could hurt somebody. 

3. Press the palms

I’ve had luck with exercises that place pressure on the palm—push-ups, upright planks, downward dog, bird dog, preacher stretches, and foam rolling the calves and hamstrings. I don’t know why, but I’ve actually had clients report improvements in their pain after incorporating these moves into their program. Still, everyone’s different, and if any of them hurt, stop doing it.

Chronic low-back pain

At any given time, some 31 million Americans experience low-back pain, and it’s now the leading cause of disability worldwide. It’s also a moving target. One person’s back pain can be completely different from another’s.

My advice: Do your research. Stuart McGill is the king here. Get a copy of Back Mechanic, read it, and refer back to it when needed.

Always listen to your client. If she says she feels a twinge in her back with a particular lift, don’t do that lift! Find another way. Don’t wait for her to speak up. Some clients may keep quiet, feeling pressured to push through. Ask questions: “How did that feel?” “Did anything hurt?” “Where did you feel it working?”

Here are the general guidelines I use with my clients.

1. Keep the spine straight

Build your programs around moves that don’t involve twisting, bending, or extending the lower back. I like the following: machine chest press, lat pulldown, seated biceps curl, dumbbell lateral raise, calf raise, band pull-apart, standing cable row, and seated machine row.

Likewise, avoid any of these:

• Standing biceps curl. These put a lot of torque on the lower back. That said, I’ve found it can be doable if the client has his back against a wall to keep the spine straight.
• Torso rotation against resistance. I avoid torso rotation machines or torso rotation with cables or bands. They put a lot of force on structures that are already compromised, aside from the fact the movement is unnatural and unnecessary for most clients. When in the real world do you need to rotate the torso against resistance?
• Shoulder press. The lower back naturally wants to go into extension when you press weights overhead, which tends to make the problem worse for someone with chronic back pain.

2. Work the core

By now every trainer understands the importance of strengthening the core muscles for just about every goal, from posture to performance. And plenty of research shows the role of core training in alleviating back pain. The trick is doing it safely.

My clients with low-back pain have had success with the following core moves:

• Suitcase and farmer’s carries
• Pallof press and other cable anti-rotation exercises
• Cable single-arm row
• Bird dog
• Seated Swiss ball crunch

READ ALSO: “Three Steps to Superior Core Training”

3. Ease into big lifts

What about deadlifts, squats, and good mornings? My rules: If a client is an experienced lifter who’s comfortable with these exercises and does them with good form, I may use them in her program. But if she’s never lifted before, or hasn’t lifted in a long time, or if any of these moves hurt, they’re off limits. Period.

When I do use them, I’ll start obnoxiously light and use a limited range of motion. So for deadlifts, I’ll have a client lift a light kettlebell from a box or bench (not the floor).

You can always bump up the weight. But if you go too heavy and the client gets hurt, it’s game over.

Knee pain

Lots of things can cause knee pain—stress, injury, or simple wear and tear over time. One major culprit is osteoarthritis (which often occurs in the hips too; we’ll get there in a moment).

More than 30 million U.S. adults suffer from osteoarthritis. Age is a risk factor, and so is excess body weight, which puts extra stress on those knees. And again, exercise has been shown to help. (Noticing a trend here?)

In fact, strengthening the quadriceps can protect knee cartilage from damage, helping to strengthen and stabilize the joint, research shows.  

But how do you work the legs without aggravating the knee? Plenty of ways.

1. Do leg curls (not leg extensions)

Some people say that leg extensions are bad for all knees, even those of healthy individuals. I’m not in that camp, but I do agree that for someone with knee pain, they’re out of the question. The biomechanics of the exercise guarantee that extensions will aggravate any pre-existing arthritis.

Leg curls are another story. A lot of my clients with knee pain just assume that any bending will hurt, and they’re pleasantly surprised when they see they can do knee flexion pain-free. As long as I keep the weight reasonable, most of them do well with it.

2. Bend the hips (not the knees)

The quadriceps have four parts (I hope this isn’t new information), three of which exclusively perform knee extension. The fourth, the rectus femoris, has a dual role that includes hip flexion.

Unless a client also has back pain that’s aggravated by working the hip flexors, you can consider any variation of leg raises, loaded or unloaded.

The rectus femoris isn’t the only muscle that acts on the knees along with another joint. The gastrocnemius acts on the ankles as well as the knee. The gracilis assists in both knee extension and hip adduction. And the hamstrings, as you surely know, perform hip extension along with knee flexion. Then there’s the gluteus medius, a hip abductor; strengthening it can reduce knee pain, even though it isn’t directly involved in knee action.  

For those reasons, I’ll include calf raises, hip adduction and abduction (using machines, cables, and/or bands), and back extensions. I’ll also use straight-leg deadlifts and, in some cases, kettlebell swings. (Yes, swings involve a slight knee bend, but I’ve found that my clients can usually tolerate it pretty well.) Again, all are contingent on the client not having lower-back issues.

Lunges and squats are out. Even push presses seem to aggravate the knees too much.

3. Work those glutes

Hip bridges, which I typically do without adding an external load, not only target the glutes and hamstrings, they fire up the quads as well. But I’ve never had a client suffer knee pain while doing them.

READ ALSO: “How to Work Around Injuries in a Group Setting”

Hip pain

Just as strengthening the surrounding muscles can help stabilize the knee, the same holds true for the hips.

In one study, patients with hip osteoarthritis reported significantly less pain and more function after just 12 weeks on a regimen of strength and balance training.

Another small study from Finland saw similar results: When 13 women with hip osteoarthritis exercised three times a week for three months, they reported, on average, 30 percent less pain and demonstrated a 30 percent improvement in range of motion.

1. Bend the knees (not the hips)

If the client’s knees are okay, I’ll start with seated leg curls and leg extensions, which allow the hamstrings and quads to work while the hips remain stable. (If the client has both knee and hip pain, of course I’ll skip the extensions.)

2. Do more hip bridges

Just as I’ve never found a client who complains of knee pain with the move, I’ve also yet to find one whose hips couldn’t handle it either. I’ll use body weight or maybe a light bar.

3. Avoid single-leg work and hip abduction

Hip abduction tends to cause pain in clients with hip problems. Sometimes clamshells are okay, but anything more intense than that isn’t worth it.

Single-leg stands can also be tough for my older clients. To help them with balance, I’ll go with heel-to-toe stands or have them stand with feet together and eyes closed; both allow them to distribute their weight through both feet.

Hernia

No amount of exercise can make a hernia better. Only surgery can do that, and surgery, of course, requires recovery. But people can live with hernias for years, and many can continue to work out (with the usual caveat about checking with a doctor first).

A hernia happens when something inside your body—an organ, an intestine, or fat or muscle tissue—protrudes through the wall of tissue that’s supposed to contain it. It usually happens in the abdominal cavity. And that’s exactly where you’re likely to increase pressure when you lift, causing the protruding thing to protrude even more and possibly making it worse.

Here’s how to keep that abdominal pressure in check.

1. Watch the ab work

I tend to steer clear of crunches, Russian twists, and ab work on a bench for the obvious reason that they can all put pressure on a hernia.

Sometimes I can get away with core exercises that don’t flex the torso, including Pallof presses, suitcase carries, and anti-rotation exercises with a band. But if the hernia is really bad, I’ll skip the ab work altogether.

2. Go light

A client with a hernia may be strong enough to push 400 pounds on the leg press, but that doesn’t mean he should. I like to lighten the load and use burnout sets and shorter rest periods, and finish sets with an extremely slow eccentric on the final rep. Or I just select a weight that’s challenging but not excessively heavy.

3. No breath holding, and no straining

Holding your breath to lift something heavy is perfectly natural. Called the Valsalva maneuver, it increases intra-abdominal pressure to protect the spine during a squat or deadlift.

But when a client has a hernia, it’s the last thing you want him to do, since that pressure will push the organs outward, aggravating the problem. You can either lighten the load until a client can breathe normally while performing it, or skip the lift entirely.

The same applies to straining. I’ll stop a set if a client strains to finish the final reps. Under normal circumstances you want the client to push himself, but with a hernia it’s not worth the risk.

Final Thoughts

No matter your exercise selection, you’ll need to take it slow with clients who have any of these conditions. That’s doubly true of someone who has more than one of them—back pain combined with knee or hip pain, for example.

Your clients will often be frustrated by their slow progress. It’s your job to stay patient and positive, and to do what you can to keep your client motivated.

But if you can pull it off, you just might get every trainer’s ultimate reward: the privilege of watching someone overcome obstacles and improve her quality of life. From experience I can tell you there’s truly nothing like it.