ACE Personal Trainer Manual, 4 th edition Chapter 15:

1. ACE Personal Trainer Manual, 4th edition Chapter 15: Common Musculoskeletal Injuries and Implications for Exercise 1

2. 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

3. 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.

4. 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.

5. 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.

6. Grading System for Ligament Sprains

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

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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 forstretching: • A fracture site that is healing • Acute soft-tissue injury • Post-surgical conditions • Joint hypermobility • An area of infection

15. 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

16. 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.

17. 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.

18. 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.

19. 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

20. 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.

21. 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

22. 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.

23. 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.

24. 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.

25. 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

26. 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.

27. 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.

28. 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

29. 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

30. 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.

31. 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.

32. 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

33. 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.

34. 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.

35. 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.

36. 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

37. 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.

38. 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

39. 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.

40. 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

41. 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.

42. 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

43. 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