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ACE Personal Trainer Manual
5th Edition
Chapter 15: Common Musculoskeletal Injuries and Implications for
Exercise
Lesson 15.1
LEARNING OBJECTIVES
• After completing this session, you will be able to:
 Identify the difference between muscle strains and ligament sprains
and the grading system of each
 Understand the main overuse conditions and how cartilage damage
and bone fractures can occur
 Discuss the healing process phases and recall signs and symptoms of
inflammation
 Explain the conservative management of common musculoskeletal
injuries
 Discuss the following injuries and recommend appropriate exercise
programming:
o
o
o
o
o
© 2014 ACE
Shoulder strain/sprain
Rotator cuff injuries
Elbow tendinitis
Carpal tunnel syndrome
Greater trochanteric bursitis
MUSCLE STRAINS
• Microscopic tears of the muscle
fibers cause swelling, discoloration
(ecchymosis), or loss of function.
• Hamstring group
 Risk factors – poor flexibility, poor
posture, muscle imbalance,
improper warm-up, and training
errors
• Groin
 Risk factors – muscle imbalance
between the hip adductors and
abductors
• Gastrocnemius and soleus
 Risk factors – muscle fatigue, fluid
and electrolyte depletion, forced
knee extension during dorsiflexion,
and forced dorsiflexion during knee
extension
© 2014 ACE
MUSCLE STRAINS GRADING SYSTEM
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LIGAMENT SPRAINS
• A joint injury that results in stretching or tearing of
the stabilizing connecting tissues causing immediate
pain, swelling, instability, decreased range of
motion (ROM), and a loss of function
• Sprains occur most often with trauma, such as
falling or during contact sports:
 Ankle
 Knee
o ACL injuries – decelerating while twisting, pivoting, and
sudden stopping or cutting motions
o MCL injuries – impact to the outer knee with no
twisting involved; or damaged at the same time as the
ACL
 Thumb or finger
 Shoulder
© 2014 ACE
LIGAMENT SPRAINS GRADING SYSTEM
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OVERUSE CONDITIONS
• Tendinitis – inflammation of the tendon:
 Commonly occurs in the shoulders, elbows, knees, and ankles
 Inflammatory response from too much demand on a tendon
caused by beginning new activities or programs too quickly
• Bursitis – inflammation of the bursa sac:
 Commonly affects the shoulders, hips, and knees
 Occurs from acute trauma, repetitive stress, muscle imbalance,
or muscle tightness on top of the bursa
• Fasciitis – inflammation of the connective tissue called fascia:
 Commonly occurs in the bottom and back of the foot
© 2014 ACE
CARTILAGE DAMAGE
• Damage to the joint surface of the knee involves damage to both:
 Hyaline cartilage – covers the articular surfaces of bones
 Menisci cartilage – in between the femur and tibia
• Meniscal injuries occur with:
 Loading or twisting of the joint and often with ACL or MCL tears
 Degeneration – degenerative joints may lead to acute tears in older
adults
• Signs and symptoms of meniscal tears:






© 2014 ACE
Joint pain
Swelling
Muscle weakness
Stiffness
Giving way
Locking, clicking, or popping
CARTILAGE DAMAGE
• Chondromalacia – a softening or wearing away
of the cartilage under the patella:
 May occur from the patella not properly
tracking
• Has been associated with:




Improper training methods
Sudden changes in training surface
Lower-extremity muscle weakness or tightness
Foot overpronation
• Signs and symptoms:
 Pain and inflammation
 Pain behind the patella during activity
 Pain that increases while walking up or down
stairs
© 2014 ACE
BONE FRACTURES
• Low-impact trauma:
 A short fall on a level surface resulting in a minor
fracture
 Repeated microtrauma to a bone region resulting
in a stress fracture
 Symptoms include:
o Progressive pain that is worse with weightbearing
activity
o Focal pain
o Pain at rest
o Local swelling
• High-impact trauma:
 Occurs in motor vehicle accidents or during highimpact sports
 Requires immediate medical attention and is
often disabling
 Pathological fractures – caused by infection,
cancer, osteoporosis, or other medical conditions
that can weaken bones
© 2014 ACE
TISSUE REACTION TO HEALING
• Inflammatory phase – can typically last for up
to 6 days
 The healing process begins and the injured
area is immobilized
 Blood flow increases to bring in oxygen and
nutrients to rebuild the damaged tissue
• Fibroblastic/proliferation phase – begins
around day 3 and lasts until around day 21
 The wound fills with collagen and other cells,
forming a scar
 Within 2 to 3 weeks, the wound can resist
normal stresses, but strength continues to
build for several months
• Maturation/remodeling phase – begins
around day 21 lasting for up to 2 years
 Remodeling of the scar, rebuilding of bone,
and/or restrengthening of the tissue
© 2014 ACE
SIGNS AND SYMPTOMS OF INFLAMMATION
• It is important to be aware of these
signs, especially for clients who are
post-injury or post-surgery:
 Pain
 Redness
 Swelling
 Warmth
 Loss of function
• The goal is to give a client a
challenging exercise program that
will not cause further damage to
an injured area.
© 2014 ACE
MANAGING MUSCULOSKELETAL INJURIES
• Pre-existing injuries:
 Determine if the client can exercise or if they must be cleared by a
physician
 The client may be able to participate in a modified program using
the non-injured body parts
• Acute injuries:
 Must be handled quickly with caution
 Refer to appropriate medical professionals
• Perform RICE:
 R – Rest or restricted activity
 I – Ice applied hourly for 10–20 minutes
 C – Compression wrap the area to minimize swelling
 E – Elevate the injured area 6–10 inches above the heart to control
swelling
© 2014 ACE
FLEXIBILITY AND MUSCULOSKELETAL INJURIES
• Decreased flexibility is associated
with various injuries, including:
 Muscle strains
 Overuse conditions
• When a muscle becomes shortened
and inflexible, it cannot lengthen
appropriately or generate adequate
force.
• A personal trainer can develop a
stretching program to:
 Address inflexibility
 Help prevent further injury
© 2014 ACE
CONSERVATIVE MANAGEMENT
© 2014 ACE
UPPER- AND LOWER-EXTREMITY INJURIES
• Upper-extremity injuries:




Shoulder strain/sprain
Rotator cuff injuries
Elbow tendinitis
Carpal tunnel
• Lower-extremity injuries:








© 2014 ACE
Greater trochanteric bursitis
Iliotibial band syndrome
Patellofemoral pain syndrome
Infrapatellar tendinitis
Shin splints
Ankle sprains
Achilles tendinitis
Plantar fasciitis
SHOULDER STRAIN AND SPRAIN
• Soft-tissue structures (bursa and rotator cuff tendons) get
abnormally stretched or compressed.
 Results from an impingement secondary to the compression and
ends up as tendinitis
 Can eventually lead to rotator cuff tears if not managed properly
• Signs and symptoms:
 Local pain that radiates down the arm
 Swelling, tenderness, pain, and stiffness
 Aggravated by lifting or reaching overhead or across the body
• Management:
 Conservative management – Table 15-3
 Avoid aggravating movements (overhead, across, or behind the body)
© 2014 ACE
EXERCISE PROGRAMMING FOR SHOULDER STRAIN AND SPRAIN
• Improve posture and body positioning
• Regain strength in the scapular
stabilizers and rotator cuff muscles
• Restore proper flexibility of the
shoulder complex
• Modify exercises as necessary to
prevent further injury
• Overhead activities:
 Will often need to be modified to
avoid pain and further injury
 Modify the movement ROM (as to
not fully extend arms)
• Use the scapular plane:
 The shoulder is positioned 30
degrees anterior of the frontal
plane.
© 2014 ACE
ROTATOR CUFF INJURIES
• Acute – related to trauma
such as falling on the
shoulder or raising the arm
against overwhelming
resistance
• Chronic – a result of a
degeneration and gradual
worsening of pain and
weakness
• Management:
 The client should see a
physician or physical
therapist
 Restriction from
performing certain
activities
 Surgery may be indicated
© 2014 ACE
• Signs and symptoms:
 A feeling of sudden “tearing”
followed by pain and a loss of
motion
 Pain when reaching overhead or
behind the back
 Pain at night or after activity
EXERCISE PROGRAMMING AFTER ROTATOR CUFF REPAIR
• Immobilization for six to eight weeks to allow
the repair to heal
• Passive ROM only to prevent re-tearing
• Potentially cleared for activity after
approximately 16 weeks or discharged from
physical therapy
• The personal trainer should:
 Obtain specific guidelines for what “should”
and “should not” be done
 Be cautious with specific shoulder positions to
avoid strain in the healing tissue, such as
limiting:
o Performing overhead activities
o Keeping the arm straight during exercise (keep
elbows bent for less torque)
o Modify exercises as necessary to prevent future
injury
© 2014 ACE
ELBOW TENDINITIS
• Lateral epicondylitis – “tennis elbow”
 Overuse or repetitive trauma injury
of the wrist extensor muscle
tendons near the origin on the
lateral epicondyle of the humerus
• Medial epicondylitis – “golfer’s
elbow”
 Overuse or repetitive trauma injury
of the wrist flexor muscle tendons
near the origin on the medial
epicondyle
• Signs and symptoms:
 Nagging elbow pain during
aggravating activities
© 2014 ACE
EXERCISE PROGRAMMING FOR ELBOW TENDINITIS
• Emphasize client education to avoid aggravating activities
• Improve posture and body positioning
• Regain strength and flexibility of the flexor/pronator and extensor/supinator
muscles in the wrist and elbow
• The client may be prescribed a wrist or elbow splint
• Modify exercises as necessary to prevent further injury
• Additionally, clients should:
 Avoid high-repetition activity (e.g., 15–20 repetitions) at the elbow and wrist
 Begin dumbbell biceps and wrist curls with low weight and repetitions
 Be cautious with full elbow extension (i.e., locking the elbow) when performing
shoulder exercises to prevent excessive loading
© 2014 ACE
CARPAL TUNNEL SYNDROME
• Repetitive wrist and finger flexion when the flexor tendons are
strained
• Results in a narrowing of the carpal tunnel due to inflammation and
median nerve compression
• Signs and symptoms:
 Gradual pain, weakness, or numbness in the radial three-and-a-half
digits and thumb
• As the condition progresses, specific symptoms occur:
 Night or early-morning pain or burning
 Loss of grip strength and dropping of objects
 Numbness or tingling in the palm, thumb, index, and middle fingers
© 2014 ACE
EXERCISE PROGRAMMING FOR CARPAL TUNNEL SYNDROME
• Emphasize client education to avoid
aggravating activities.
• Improve posture and body positioning
• Regain strength and flexibility of the
elbow, wrist, and finger flexors and
extensors.
• The client may be prescribed a wrist
splint.
• Modify exercises as necessary to
prevent further injury.
• Additionally, clients should:
 Avoid movements that involve full wrist
flexion or extension, which can further
compress the carpal tunnel and
increasing symptoms
 Focus on exercising in the mid-range of
flexion or extension
© 2014 ACE
SUMMARY
• All personal trainers work with clients who have
sustained, or will sustain, an injury in the course of their
activities.
• Learning to recognize the signs and symptoms of
inflammation and knowing the proper steps in acute
injury care can allow the trainer to help the injured
client recover more quickly.
• All trainers should receive as much training as is
available in first aid and injury recognition.
• An understanding of how the body reacts to injury and
resulting repair will help clients plan an appropriate
program.
© 2014 ACE