Chapter 21b Clients with Orthopedic, Injury and Rehabilitation Concerns

1. Chapter 21b Clients with Orthopedic, Injury and Rehabilitation Concerns NSCA’s Essentials

2. Shoulder • Because of the type of joint and area of the shoulder, it is a structure that can be susceptible to injury • The following sections discuss indicated and contraindicated exercises, strategies, etc. for clients with shoulder issues • The trunk and hips are vital to shoulder function, the legs provide 51-55% of the total kinetic energy and total force for overhead activities. • A program for shoulder health should include strengthening exercises for the hip rotators, hip abductors, and hip extensors, as well as the abdominal and low back stabilizing muscles

3. Shoulder • Shoulder Impingement Syndrome • Essentially is pinching of the supraspinatus (part of the rotator cuff…remember SITS), the long head of the biceps or the bursa underneath the acromial arch (subacromial bursa) • Can be treated conservatively or with surgical procedures • Causes for surgical procedures include: • Abnormalities of bone (example…a hook acromion process that compresses structures)

4. Shoulder • Factors that may be altered • Muscular imbalances • ROM (if limited) • Poor posture • Poor scapula control • Poor and improper exercise technique • Overuse issues of the shoulder (overhead activities…what are some examples of overhead activities that could contribute to this problem?)

5. Shoulder • Movement and Exercise Guidelines • See Figures 21.5 to 21.9 (pg. 545-546) (series of exercises recommended for rotator cuff activation with minimal use of other muscle groups) • These are very common exercises use in non-surgical and surgical rehab programs • The rotator cuff muscles have a primary function in endurance so these exercises are performed typically in this manner: • Light weights (really no more than 4 or so pounds) • High reps (15-20)

6. Shoulder • The other great thing about these exercises is that they put the shoulder in a safe position • This position is neutral environments below 90 degrees of elevation with the arm in a forward position relative to the body (think anterior to frontal plane…remember frontal plane…abduction/adduction) • These exercises are great for pain free exercises and decreasing chances of shoulder impingement

7. Shoulder • Clients need to concentrate on strengthening rotator cuff and scapula muscles • For example…rowing exercising (seat row, etc.) are great for increasing rhomboid and trapezius strength • Overhead pressing activities and bench press should be used cautiously (decline bench may be better = inside safe zone) • Upright row should be used cautiously as well (rowing elbows too high can aggravate the impingement type pain) • Some cardio equipment may be a problem as well (versa-climbers place the arm above the head and could cause impingement aggravation) • Racket sports should be used with caution as serving overhead or smashing a shot from high above and down could cause aggravation

8. Shoulder • Anterior Instability • This is when the glenohumeral joint moves too far forward, which then can cause injury such dislocation • Following dislocation, re-dislocation is a high possibility (90% in young active individuals, 30-50% in middle aged individuals…why the difference?) • This is a difficult rehabilitation areas due to the laxity and instability of this area structurally

9. Shoulder • Movement and Exercise Guidelines • Indications for strengthening instability are similar to impingement (strengthen rotator cuff and scapula muscles) • Use similar exercises like in 21.5-9 (pg. 545-546) • Movements that are contraindicated and could lead to dislocation: • Greater than 90 degrees of elevation • Hands and arms behind plane of shoulder • Follow safe zone guidelines: • Activities below 90 degrees of elevation of the shoulder (see figure 21.10 pg. 548) • Arms anterior to frontal plane of the body (see figure. 21.10 pg. 548)

10. Shoulder • Rotator Cuff Repair • Carried out when damage to the rotator cuff tendons-most often the tendon of the supraspinatus muscle-occurs • These tears cause altered joint mechanics and usually require arthroscopic surgery. • Two days to six weeks in a sling, but surgeon decides on recovery time

11. Shoulder • Ultimately clients may choose a conservative approach based on exercise or choose surgery • Allow for exercise modifications regardless of choice to protect structures • Even with treatment completed clients should try to remain in safe zone in activities • Exercises outside of the safe zone are contraindicated

12. Shoulder • Movement and Exercise Guidelines • Often discharged from formal rehabilitation three to four months following the surgery • Contraindicated exercises listed in table 21.4, pg. 547 • Contraindicated exercises • High resistance training and low-repetition upper extremity strengthening • Exercises outside of the safe zone • Examples of exercises: • Shoulder press • Bench press • Behind the neck lat pulldown • Racket sports • swimming

13. Shoulder • Movement and Exercise Guidelines • Exercises 21.5-9 are also applied for strengthening after rotator cuff repair, but usually not until four to six weeks after surgery • Table 21.4 provide contraindicated activities • Overhead lifting and push ups/bench press are contraindicated (can result in overload of cuff) • Lower body aerobic exercises are well suited (walking, running, etc.)

14. Shoulder • Conditions Requiring Shoulder Exercise Modification • Rotator Cuff Repair • Rotator Cuff Tendonitis • Glenohumeral joint instability (prior dislocation, etc.) • Acromioclavicular joint injury (separation) • Glenohumeral joint osteoarthritis) • See Table 21.5 (pg. 550) for “Shoulder Exercise Modifications”

15. Shoulder • So…let’s take some time and go through the pictured exercises on pg. 545-546 of your text and Table 21.5 on pg 550 • Let’s get to it!

16. Knee • Anterior Knee Pain • Common knee issues include: • Chondromalacia • Iliotibial band friction syndrome • Irritated plica • Patellar tendonitis • Client with these issues commonly describe pain from prolonged sitting and walking up and own stairs • Lots of times diagnosis is based upon overuse, biomechanical issues, and muscular imbalances • Rehabilitation focuses on reducing pain and inflammation, correcting biomechanical faults and optimizing tissue function

17. Knee • Movement Exercise Guidelines • Increase quadriceps strength as it improve functional activities (walking up and down stairs) and increasing patellofemoral function and reduces knee pain • Deep squats, closed kinetic chain activities or exercises requiring knee flexion more than 90 degrees should be used cautiously • Aerobic activities that require deep squatting or lunging should be avoided (contraindicated) • Cycling or water based activities can be used to maintain client’s aerobic base • It is common for anterior knee pain clients to use some form of taping or patellar support

18. Knee • Anterior Knee Pain • Movement contraindications (table 21.7, pg. 553) • Closed chain knee movements with > 90 degrees of knee flexion • Open chain knee movements 0 to 30 degrees of knee flexion • Exercise contraindications • Closed chain: full squat, full lunge • Open chain: end range leg extension, stair stepper with large steps • Exercise indications • Closed chain: ¼ to ½ squat and leg press • Open chain: partial lunge; leg curl, stair stepper with short, choppy steps

19. Knee • Anterior Cruciate Ligament Reconstruction • Exercise after ACL reconstruction is vital to recovery • ACL controls knee motion and proprioceptive feedback • Recent reconstruction technology advances have allowed for a speedier recovery from ACL tears • A graft of the central third of the patellar tendon or the hamstring is usually the graft source • Emphasis on reducing inflammation

20. Knee • Movement and Exercise Guidelines • Post-operative contraindications include: • Immediate active or resistive knee flexion until six weeks after surgery • Hamstring grafts preclude immediate post-operative active or resistive knee flexion until approximately three to four weeks following surgery • For either graft discharge can be as early as four to six weeks • During rehab open (straight leg raises, leg curl, extension, abduction, etc.) and closed kinetic chain (lunges, squats, leg press, etc.) activities are recommended and important • Leg extension exercises should be performed with a range of motion of 90 degrees of knee flexion to 45 degrees of knee extension to decrease stress on ACL (adhere to this for a minimum of six months to a year)

21. Knee • Open chain vs. Closed chain • Open chain • Exercises that have the distal aspect of the extremity terminating free in space. • Ex: leg curl/extension, hip flexion/extension • Closed chain • Exercises that occur with the distal part of the extremity fixed to an object that is either stationary or moving. • Ex: leg press, squat, step-ups, barbell bench press

22. Knee • Movement and Exercise Guidelines (Table 21.7, pg. 553) • Movement contraindications • Open chain knee movements with <45 degrees knee flexion • Active hamstring exercise (those with hamstring graft) for four to six weeks • Exercise contraidications • End range of leg extensions • Exercise indications • ¾ squat and leg press • Step-up • Leg curl • Stiff-legged deadlift • Elliptical trainer

23. Knee • Total Knee Arthoplasty • Total knee replacement…generally due to year of stress and repetitive load on the knee (degeneration on the joint surfaces of the distal femur and proximal tibia) • Prosthetic components are inserted to cover worn areas at the ends of both the femur and tibia • Rehab is immediate with range of motion the focus • Emphasis on range of motion

24. Knee • TKA • Movement and Exercise Guidelines • Contraindications • Movements greater than 100 degrees of flexion are risky and can cause undue stress on knee • Exercises requiring kneeling (bent-over dumbbell row, lunges too deeply • Indications • Exercises using less than 90 degrees knee flexion postures are recommended in both open and closed kinetic chain exercises • Cycling • Swimming • Endurance-based activities that minimize joint impact loading • Specific resistance exercises such as leg press, calf raise and knee flexion with low resistance and high reps

25. Knee • TKA (movement and exercise guidelines) • Movement contraindications (Table 21.7, pg. 553) • Closed chain knee movements wth > 100 degrees knee flexion • Kneeling • Exercise contraindications • Full squat • Full lunge • Exercise indications • ¼ to ½ squat and leg press • Partial lunge • Leg extension and leg curl • Stationary bicycle • Aquatics, swimming

26. Hip • Trainers will encounter very few hip injuries or procedures • Hip is much more stable than shoulder or knee joint

27. Hip • Hip Arthroscopy • Post-procedure • Focus on restoration of ROM, strength, and gait • Total time to return to activity is about 16 to 32 weeks but is determined by the extent of the surgical repair

28. Hip • Hip arthroscopy • Movement and exercise guidelines (Table 21.8, pg. 557) • Movement contraindications • Forceful hip flexion • Hip abduction and rotation (early phase of rehabilitation) • Exercise contraindications • Ballistic or forced stretching • Exercise indications • Aquatic walking

29. Hip • Total Hip Arthroplasty (Hip Replacement) • Usually recommend if non-surgical procedures do not work • Replacement of hip provides about 15 years of pain free movement • Two types of prostheses • Cemented • Affixing the femoral and acetabular components with bone cement • Uncemented • Allow direct attachment of the prosthetic components to the bone

30. Hip • Cemented allows for immediate post-op weight bearing • Uncemented need six to twelve weeks wait time before weight bearing after surgery • THA restrictions • No hip flexion greater than 90 degrees • No hip adduction past neutral • No hip internal rotation

31. Hip • Movement and Exercise Guidelines (Table 21.9, pg. 558) • Trainer should first contact surgeon to see if there are any other restrictions for exercise • Weight bearing status: • Posterolateral approach: Immediate full weight bearing • Anterolateral approach: Restricted weight bearing for ≥ 6 weeks • Transtrochanteric approach: Restricted weight bearing for ≥ 6 weeks • ROM limitations • Posterolateral approach: Flexion > 90 degree, abduction, medial rotation • Anterolateral approach: Extension, adduction, lateral rotation • Transtrochanteric approach: Extension, adduction, lateral rotation • Functional movement precautions • Moving in and out of a chair, hip flexion (putting shoes on) • Turning away from surgical hip • Turning away from surgical hip

32. Arthritis • Two primary arthritis classifications • Osteoarthritis • Degenerative joint disease • Progressive destruction of joint’s articular cartilage • Rheumatoid Arthritis • Systemic inflammatory disease affecting not only the joint surface, but also connective tissue (capsules and ligaments)

33. Arthritis • Osteoarthritis • Movement Exercise Guidelines (Table 21.10, pg. 559) • Movement contraindications • High-impact activites • Exercise contraindications • running • Snow skiing • Jogging • Exercise indications • Bicycle • Stair stepper • Elliptical trainer • Aquatics, swimming

34. Arthritis • Rheumatoid Arthritis • Movement and Exercise Guidelines (21.11, pg. 560) • Improve function during daily activities • Improve general health • Protect affected joints • Movement contraindications • High-impact cardiovascular exercise • Neck flexibility or strangthening in clients with history of neck instability • Movements outside the safe zone • Exercise contraindications • Running or jogging • Upper trapezius stretch • Manually resisted neck strengthening • Behind-the-neck shoulder press • Exercise indications • Moderate-intensity (60-80% maximal heart rate), aerobic endurance exercise • Range of motion and flexibility exercises • Isometric exercise (for the unstable joint) • Water aerobics • Stationary bicycling

35. Arthritis • Common Modifications to Exercise • Common affected areas are cervical spine, shoulders and wrists • Cervical spine • Avoid neck stretching or manual resistance in that area • Shoulders • Avoid impingement prone positions (upright row) • Wrists • Increase diameter of bar, dumbbell or handle to offset weakened grip • May add a padding to a dumbbell bar