ACE Personal Trainer

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ACE Personal Trainer Manual, 4th edition
Chapter 15 Common Musculoskeletal Injuries and
Implications for Exercise
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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

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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.

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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.

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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.

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Grading System for Ligament Sprains
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Overuse Conditions

• When the body is put through excessive demands
  during activity, it often results in overuse
  conditions such as
• Tendinitis
• Bursitis
• Fasciitis

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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.

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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.

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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

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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

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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

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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

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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 clients 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

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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

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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.

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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.

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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.

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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

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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.

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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

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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.

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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.

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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.

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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

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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.

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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.

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Patellofemoral Pain Syndrome

• Patellofemoral pain syndrome (PFPS) is often
  called anterior knee pain or runners 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

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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

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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.

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Infrapatellar Tendinitis

• Infrapatellar tendinitis, or jumpers 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.

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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

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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.

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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-mileage
  conditioning and cross-training
• However, the best intervention may just be to
  rest.

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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.

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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

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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.

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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

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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.

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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

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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 foots intrinsic muscles and the
  calf complex.

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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

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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