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ACE Personal Trainer Manual, 4th edition

Chapter 15: Common Musculoskeletal Injuries

and Implications for Exercise

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 side-stepping.

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/post-surgery 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 early-intervention 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

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 inphysical therapy in a safe, progressive manner.

Performing overhead activities or keeping thearm straight during exercise should be limited.

Exercises with the elbows bent will createless 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

– Repetitive-trauma injury of the wrist extensor muscle tendons near their origin on the lateral epicondyle

Medial epicondylitis

– Repetitive-trauma injury of the wrist flexor muscle tendons near their origin on the medial epicondyle

Signs and symptoms

– Nagging elbow pain at the lateral ormedial epicondyle

Medical management

– Conservative management formusculoskeletal 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, andmiddle 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 onrestoring proper strengththroughout the hip, knee,and ankle with closed-chainmovements.

Open-chain knee activitysuch as leg extensionsshould 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 thedistal posterior medial tibia.

– Anterior shin splint sufferers complain of the sametype of pain along the distal anterior shin.

Medical management

– Modifying training with lower-impact/lower-mileageconditioning 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 bemedial swelling with tendernessover 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