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different injuries in the shoulder but it could also be cancer of the lung. At 90 degrees of shoulder abduction, the lung moves, so pain in this area is a potential indication of a tumor in the lung. 3 If a client came in with pain in both heels, what would you think? This is one symptom of the potentially deadly disseminated gonococcal infection. 4 To assess and work the cases mentioned above, a therapist would require a fair amount of training. Unfortunately, some therapists are under the illusion that just giving a massage or a deep-tissue treatment alone is sufficient to fix most problems. This is dangerous for many reasons. The client could be badly injured by the treatment. Or, the client may never try massage again because of a bad experience, which damages everyone in the profession. When people have bad experiences, the word spreads. Knowledge of Endangerment Sites Every therapist, not only those who specialize in working with pain and injury, needs to know the endangerment sites for each body part. Knowing where not to work is as important as knowing where to work. For example, it's essential to avoid applying too much pressure to the ulna nerve at the elbow, or the radial nerve in the lateral posterior forearm, or the anterior triangle and brachial plexus in the neck or the back of the knee, or the aorta when working the psoas muscle. These are all crucial parts of training that keep clients and therapists safe. PATHWAYS TO LEARNING AND MASTERY Critical Thinking Training in how to work with pain and injury conditions is about learning how to think critically. It means being a certain kind of detective. Critical thinking is the most crucial and time-consuming part of the learning and therapeutic process. It means taking all you have learned and applying it to something you may have never seen before. It means figuring out things that at first seem a little confusing. There are hundreds of injury and pain conditions that are impossible to learn in an online setting only, because you need hands-on experience with the instructor right there to help you. You will frequently be confronted with new things. If you know your anatomy, know how to gather all the information you need directly from the client and from online and other research, and know all the assessment tests, then you will likely be able to figure out the majority of problems you encounter. Live Clinic Learning In my opinion, the most effective way to complete the learning process of how to assess and treat injuries is to participate in multiple live injury clinics. This can occur in a one-on-one mentorship setting or in a classroom/workshop. These learning clinics occur after you have learned the palpation anatomy, history taking, assessment testing, treatment techniques, and critical thinking skills to put it all together. Clients come to a free clinic and are assessed and treated by a team of student practitioners. The students decide who takes which part of the history, who does which segment of the physical assessment testing, and who records the notes and the findings. 66 m a s s a g e & b o d y w o r k m a y / j u n e 2 0 1 8 foot causes no, or minimal, referred pain. Without an understanding of referred pain, a therapist might work on the area of the referred pain, which is often 6–12 inches away from the source of the injured tissue, wasting the client's time and money, and delaying proper treatment. It is not possible to be a skilled practitioner who works with musculoskeletal pain and injury without an understanding of referred pain. Let me give you a few examples. A client comes in with pain at the medial border of the scapula. The first question is, has the client been seen by a physician to check out serious conditions? This type of discomfort could be referred pain from one particular ligament in the neck or it could be referred pain from an inflamed gall bladder or other visceral condition. 2 If you have the assessment skills, you can see if you can elicit the pain with one of six passive assessment tests of the neck and palpation of the ligaments that can cause this referred pain. In this case, with your knowledge and the results of the physician's medical assessment (which should occur before or soon after initial assessment), you can ensure that the client is safe and receives the right treatment. Do you know what it means when there is pain in the shoulder and upper chest when lifting the arm to the side? It could be many