Download PT Manual Ch 15

ACE Personal Trainer
Manual, 4th edition
Chapter 15:
Common Musculoskeletal Injuries
and Implications for Exercise
1
Learning Objectives
 This session, which is based on Chapter 15 of the ACE Personal
Trainer Manual, 4th edition, describes how to develop programs for
clients with pre-existing musculoskeletal injuries in order to minimize
the risk of further injury.
 After completing this session, you will have a better understanding
of:
– The signs and symptoms of inflammation
– The relationship between flexibility and musculoskeletal injuries
– Common upper-extremity injuries
– Common lower-extremity injuries
– The causes of low-back pain
– The importance of proper and thorough record-keeping procedures
Introduction
 When there is an injury to the human body, a variety of structures
can be damaged, including:
– Bone
– Cartilage
– Ligaments
– Muscle
– Skin
– Nerves
– Blood vessels
– Viscera
 Having a basic understanding of common musculoskeletal injuries
helps a personal trainer provide safe and effective exercise
programming and make appropriate referrals.
Muscle Strains
 Muscle strains are injuries in which the muscle works beyond its
capacity.
– Result in microscopic tears of the muscle fibers
– Frequent in the lower extremity and primarily occur in major muscle
groups
 The table at right provides a
description of the grades of
muscle strains.
 Muscle strains of the hamstrings,
adductors, and calves are most
common.
Ligament Sprains
 Ligament sprains often occur with trauma.
 Of particular medical significance are injuries to the:
– Anterior cruciate ligament (ACL)
– Medial collateral ligament (MCL)
 The mechanism of an ACL injury
often involves deceleration of the
body, combined with a maneuver
of twisting, pivoting, or sidestepping.
Grading System for Ligament Sprains
Overuse Conditions
 When the body is put through excessive demands during
activity, it often results in overuse conditions such as:
– Tendinitis
– Bursitis
– Fasciitis
Knee Cartilage Damage
 Damage to the joint surface of the knee often involves
damage to both the:
– Hyaline cartilage
– Menisci cartilage
 The most commonly reported knee injury is damage to
the menisci.
 The cartilage under the patella can also become
damaged, resulting in chondromalacia.
Bone Fractures
 The causes of bone fractures are
classified as either low or high
impact.
– Low-impact trauma can result in a minor
fracture or a stress fracture.
– High-impact trauma injuries are often
disabling and require immediate medical
attention.
 Other medical conditions
such as infection, cancer,
or osteoporosis can weaken
bone and increase the risks
for fracture.
Tissue Reaction to Healing

When an injury occurs, the body goes through a systematic process with
three distinct phases.

Inflammatory phase
– Can last for up to six days
– The focus is to immobilize the injured area and begin the healing process.

Fibroblastic/proliferation phase
– Begins approximately at day 3 and lasts approximately until day 21
– Starts with the wound filling with collagen and other cells, which eventually forms
a scar
– Wound strength continues to build for several months

Maturation/remodeling phase
– Begins approximately at day 21, and can last up to two years
– Remodeling of the scar, rebuilding of bone, and/or restrengthening of tissue into
a more organized structure
Signs and Symptoms of Inflammation
 The goal when training post-injury, post-rehabilitation, or
post-surgery clients who have medical clearance to
exercise is to give them a challenging exercise program
that will not cause further damage.
 The signs and symptoms of tissue inflammation are:
– Pain
– Redness
– Swelling
– Warmth
– Loss of function
Managing Pre-existing Injuries
 It is important for a trainer to answer the most important question:
– “Is the client appropriate for exercise or should he or she be cleared by a medical
professional?”
– With local injuries, the client should be able to exercise using the non-injured
parts of the body.
 The program must be modified if symptoms of post-injury/postsurgery overtraining occur:
– Soreness that lasts for more than 24 hours
– Pain when sleeping or increased pain when sleeping
– Soreness or pain that occurs earlier or is increased from the prior session
– Increased stiffness or decreased ROM over several sessions
– Swelling, redness, or warmth in healing tissue
– Progressive weakness over several sessions
– Decreased functional usage
Acute Injury Management
 If an acute injury occurs, early intervention often includes
medical management.
 The acronym P.R.I.C.E. describes a safe earlyintervention strategy for an acute injury.
– Protection
– Rest or restricted activity
– Ice
– Compression
– Elevation
Flexibility and Musculoskeletal Injuries

When a muscle becomes shortened and inflexible, it cannot lengthen appropriately or
generate adequate force.

Relative contraindications for stretching to prevent injury:

–
Pain in the affected area
–
Restrictions from the client’s doctor
–
Prolonged immobilization of muscles and connective tissue
–
Joint swelling (effusion) from trauma or disease
–
Presence of osteoporosis or rheumatoid arthritis
–
A history of prolonged corticosteroid use
Absolute contraindications for stretching:
–
A fracture site that is healing
–
Acute soft-tissue injury
–
Post-surgical conditions
–
Joint hypermobility
–
An area of infection
Shoulder Strain/Sprain

Shoulder strain/sprain occurs when the soft-tissue structures get abnormally
stretched or compressed.

Signs and symptoms
–
Local pain at the shoulder that radiates down the arm

Medical management

Contraindicated movements:
–
Overhead and across-the-body movements
–
Any movements that involve
placing the hand behind the back
Exercise Programming Following
Shoulder Strain/Sprain Rehabilitation

Focus on improving posture and body positioning.

The exercise program should emphasize regaining strength and flexibility of
the shoulder complex.

Focus on stretching the major muscle groups around the shoulder to restore
proper length.

Overhead activities often need
to be modified.
Rotator Cuff Injuries

Common among individuals who engage in activities that involve reaching
the arms overhead repeatedly, as well as among middle-aged individuals

Rotator cuff injury can be classified into two main categories.
– Acute
– Chronic

Signs and symptoms
– Acute tears result in a sudden “tearing” sensation followed by immediate pain
and loss of motion.
– Chronic tears show a gradual worsening, with increased pain at night or after
increased activity.

Medical management
– The client is typically restricted from performing overhead activities and lifting
heavy objects.
– If there is no progress with physical therapy or the tear is too severe, surgery is
indicated to repair the torn muscle.
Exercise Programming Following
Rehabilitation for Rotator Cuff Injuries
 The personal trainer must obtain specific exercise guidelines from
the physical therapist/surgeon.
 Focus on improving posture and body positioning.
 The goal is to continue what has been done in
physical therapy in a safe, progressive manner.
 Performing overhead activities or keeping the
arm straight during exercise should be limited.
 Exercises with the elbows bent will create
less torque on the healing muscles.
Elbow Tendinitis

Tendinitis of both the flexor and extensor muscle tendons of the elbow and wrist can
occur with overuse.

Lateral epicondylitis
–

Medial epicondylitis
–

Repetitive-trauma injury of the wrist flexor muscle tendons near their origin on the medial
epicondyle
Signs and symptoms
–

Repetitive-trauma injury of the wrist extensor muscle tendons near their origin on the lateral
epicondyle
Nagging elbow pain at the lateral or
medial epicondyle
Medical management
–
Conservative management for
musculoskeletal injuries
Exercise Programming Following
Elbow Tendinitis Rehabilitation
 Focus on improving posture and body positioning.
 Regain strength and flexibility of the flexor/pronator and
extensor/supinator muscle groups.
 Avoid high-repetition activity at the elbow and wrist.
 Full elbow extension when performing shoulder raises
should be done with caution.
Carpal Tunnel Syndrome

Carpal tunnel syndrome is the result of repetitive wrist and finger flexion
leading to a narrowing of the carpal tunnel due to inflammation.

Signs and symptoms

–
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
–
Long-standing effects may include atrophy of the thumb
side of the hand, loss of sensations, and paresthesias.
Medical management
–
Conservative management for musculoskeletal injuries,
with the exception of cortisone injections
–
May be prescribed wrist splints to wear during activity
Exercise Programming Following
Carpal Tunnel Syndrome Rehabilitation
 Focus on improving posture and body positioning.
 Emphasize regaining strength and flexibility of the elbow,
wrist, and finger flexors and extensors.
 Avoid movements that involve full wrist flexion or
extension.
Low-back Pain
 Causes of low-back pain are commonly categorized into:
– Mechanical problems
– Degenerative disc disease (DDD) and sciatica
 Exercise precautions
– Avoid repeated bending and twisting of the spine
– Clients should learn how to stabilize the trunk with a moderate
lordosis or “neutral” position and also use back support during
overhead activities.
Greater Trochanteric Bursitis
 Greater trochanteric bursitis is characterized by inflammation of the
greater trochanteric bursa.
– May be due to an acute incident or repetitive (cumulative) trauma
– More common in female runners, cross-country skiers, and ballet dancers
 Signs and symptoms
– Trochanteric pain and/or parasthesias
– Symptoms are most often related to an increase in activity or repetitive overuse.
– The client may walk with a limp
 Medical management
– Conservative management for musculoskeletal injuries
– Clients should use an assistive device such as a cane as needed.
Exercise Programming Following Rehabilitation
for Greater Trochanteric Bursitis

The program should focus on regaining flexibility and strength at the hip and
include proper posture awareness.

Stretching focus:
– Iliotibial band complex
– Hamstrings
– Quadriceps

Strengthening focus:
– Gluteals
– Deep rotators of the hip

Proper gait mechanics in walking and running should be a priority.

Aquatic exercise is well-tolerated.

Contraindicated movements:
– Side-lying positions that compress the lateral hip
– Higher-loading activity such as squats or lunges
Iliotibial Band Syndrome
 Iliotibial band syndrome (ITBS) is a repetitive overuse
condition.
– Occurs when the distal portion of the iliotibial band rubs against
the lateral femoral epicondyle
 Primarily caused by training errors.
 Signs and symptoms
– Radiating or sharp “stabbing” pain at the lower lateral knee
– Aggravating factors may include any repetitive activity
 Medical management
– Conservative management for musculoskeletal injuries
– Clients should use an assistive device such as a cane as
needed.
Exercise Programming Following
ITBS Rehabilitation

Focus on improving posture and body positioning.

The exercise program should focus on regaining flexibility and strength at
the hip and lateral thigh.

Aquatic exercise is well-tolerated.

Contraindicated movements:
– Higher-loading activities such as lunges or squats

Lunges and squats limited to 45 degrees of knee flexion can be introduced
with a progression to 90 degrees and beyond, if tolerated.
Patellofemoral Pain Syndrome
 Patellofemoral pain syndrome (PFPS) is often called “anterior knee
pain” or “runner’s knee.”
 The cause of PFPS can be classified into three primary categories:
– Overuse
– Biomechanical
– Muscle dysfunction
 Signs and symptoms
– Pain with running, ascending or descending stairs, squatting, or
prolonged sitting
– A gradual “achy” pain that occurs behind or underneath the patella
– Knee stiffness, giving way, clicking, or a popping sensation during
movement
Medical Management of PFPS

Avoid aggravating activities:
– Prolonged sitting
– Deep squats
– Running (particularly downhill running)

Modify training variables

Proper footwear

Physical therapy

Patellar taping

Knee bracing

Foot orthotics

Client education

Oral anti-inflammatory medication

Modalities
Exercise Programming Following
PFPS Rehabilitation
 Restoring proper flexibility and strength is the key with PFPS.
 Stretching
– IT band complex
– Hamstrings
– Calves
 Exercise should focus on
restoring proper strength
throughout the hip, knee,
and ankle with closed-chain
movements.
 Open-chain knee activity
such as leg extensions
should be done with caution.
Infrapatellar Tendinitis
 Infrapatellar tendinitis, or “jumper’s knee,” is an overuse
syndrome characterized by inflammation of the distal patellar
tendon.
 Potential causes include:
– Improper training methods
– Sudden change in training surface
– Lower-extremity inflexibility
– Muscle imbalance
 Signs and symptoms
– Pain at the distal kneecap
– Pain has also been reported with running, walking stairs, squatting, or
prolonged sitting.
Medical Management of
Infrapatellar Tendinitis

Avoid aggravating activities:
–
Plyometrics
–
Prolonged sitting
–
Deep squats
–
Running

Modify training variables

Proper footwear

Physical therapy

Patellar taping

Knee bracing

Arch supports

Foot orthotics

Client education

Oral anti-inflammatory medication

Modalities
Exercise Programming Following
Rehabilitation for Infrapatellar Tendinitis
 The program focus is to restore proper flexibility and
strength in the lower extremity.
 Stretching
– Quadriceps
– Iliotibial band
– Hamstrings
– Calves
 Exercise should focus on restoring strength throughout
the hip, knee, and ankle.
 High-impact activities such as running or plyometrics are
contraindicated.
Shin Splints



Shin splints are typically classified as one of two specific conditions:
–
Medial tibial stress syndrome (MTSS), also called posterior shin splints
–
Anterior shin splints
Signs and symptoms
–
MTSS sufferers complain of a “dull ache” along the
distal posterior medial tibia.
–
Anterior shin splint sufferers complain of the same
type of pain along the distal anterior shin.
Medical management
–
Modifying training with lower-impact/lower-mileage
conditioning and cross-training
–
However, the best intervention may just be to rest.
Exercise Programming Following
Rehabilitation for Shin Splints
 Cross-training to maintain adequate levels of fitness is
indicated in the early stages.
 Stretching
– Pain-free stretching of the calf muscles, especially the soleus, for
MTSS
– Stretching of the anterior compartment for anterior shin splints
 Rest and modified activity are the primary interventions
for symptom relief.
 These clients may be sensitive to a rapid return to
activity or an extreme change in surfaces.
Ankle Sprains
 Lateral, or inversion, ankle sprains are the most common type.
 Medial, or eversion, ankle sprains are relatively rare.
 Signs and symptoms
– With lateral ankle sprains, the individual can often recall hearing a “pop”
or “tearing” sound and experiences swelling over the lateral ankle.
– With medial sprains, there may be
medial swelling with tenderness
over the deltoid ligament.
 Medical management
– Immobilization and physical therapy
Exercise Programming Following
Rehabilitation for Ankle Sprains
 The client can return to exercise for non-injured regions,
such as the upper body.
 Restoring proper proprioception, flexibility, and strength
is the key.
 Stretching and strengthening of the lower limb is
indicated, along with training for balance.
 Targeting the peroneal muscle group for inversion ankle
sprains is important for prevention of re-injury.
 Progress clients first with straight-plane motions, then
side-to-side motions, and then multidirectional motions.
Achilles Tendinitis

Achilles tendinitis can eventually lead to a partial tear or rupture of the
Achilles tendon if not addressed appropriately.

A multifactorial condition that includes a combination of intrinsic and
extrinsic factors.

Signs and symptoms

–
Pain that is 2 to 6 cm (0.8 to 2.3 inches) above the tendon insertion into the calcaneus
–
Initial morning pain that is “sharp” or “burning” and increases with more vigorous activity
Medical management
–
Controlling pain and inflammation with modalities and anti-inflammatory medication
–
Proper training techniques
–
Losing weight
–
Proper footwear
–
Orthotics
–
Strengthening and stretching
Exercise Programming Following
Rehabilitation for Achilles Tendinitis
 Controlled eccentric strengthening of the
calf complex
 Restore proper length to the calf muscles.
– However, overstretching of the Achilles
tendon can cause irritation.
– When stretching the calf in a standing
position, the client should wear supportive
shoes.
– The client should be taught to properly
position the back foot to point straight
ahead.
Plantar Fasciitis
 Plantar fasciitis is an inflammatory condition of the plantar
aponeurosis.
– Intrinsic factors:
• Pes planus
• Pes cavus
– Extrinsic factors:
• Overtraining
• Improper footwear
• Obesity
• Unyielding surfaces
 Signs and symptoms
– Pain on the plantar, medial heel at its calcaneal attachment
– Excessive pain during the first few steps in the morning
Management and Exercise Programming
Following Rehabilitation for Plantar Fasciitis
 Conservative management of this condition may
include:
– Modalities
– Oral anti-inflammatory medication
– Heel pad or plantar arch
– Stretching
– Strengthening exercises
 A doctor may prescribe physical therapy, a night
splint, or orthotics, or inject the area with cortisone.
 The goal is to design a program that challenges
the client but does not excessively load the foot.
– Stretch the gastrocnemius, soleus, and plantar fascia.
– Strengthen the foot’s intrinsic muscles and the calf
complex.
Record Keeping
 Keeping current and accurate records for every client is
essential for a personal trainer.
 The following information should be retained for every
client:
– Medical history
– Exercise record
– Incident report
– Correspondence
Summary
 The key when working with injured or post-injury clients is
avoiding exercises that aggravate pre-existing conditions.
 This session covered:
– Types of tissue and common tissue injuries
– Tissue reaction to healing
– Managing musculoskeletal injuries
– Flexibility and musculoskeletal injuries
– Upper-extremity injuries
– Low-back pain
– Lower-extremity injuries
– Record keeping