Chapter 21b Clients with
Orthopedic, Injury and
Rehabilitation Concerns
NSCA’s Essentials
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
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)
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?)
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 nonsurgical 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)
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
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 (versaclimbers 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
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, 3050% in middle aged individuals…why the
difference?)
This is a difficult rehabilitation areas due to the
laxity and instability of this area structurally
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)
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
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
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
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.)
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”
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!
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
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
Knee

Anterior Knee Pain

Movement contraindications (table 21.7, pg. 553)



Exercise contraindications



Closed chain knee movements with > 90 degrees of knee
flexion
Open chain knee movements 0 to 30 degrees of knee flexion
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
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
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)
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
Knee

Movement and Exercise Guidelines (Table 21.7, pg. 553)
 Movement contraindications



Exercise contraidications


Open chain knee movements with <45 degrees knee flexion
Active hamstring exercise (those with hamstring graft) for four to six
weeks
End range of leg extensions
Exercise indications





¾ squat and leg press
Step-up
Leg curl
Stiff-legged deadlift
Elliptical trainer
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
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
Knee

TKA (movement and exercise guidelines)

Movement contraindications (Table 21.7, pg. 553)



Exercise contraindications



Closed chain knee movements wth > 100 degrees knee flexion
Kneeling
Full squat
Full lunge
Exercise indications





¼ to ½ squat and leg press
Partial lunge
Leg extension and leg curl
Stationary bicycle
Aquatics, swimming
Hip


Trainers will encounter very few hip
injuries or procedures
Hip is much more stable than shoulder
or knee joint
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
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
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
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
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:




ROM limitations




Posterolateral approach: Immediate full weight bearing
Anterolateral approach: Restricted weight bearing for ≥ 6 weeks
Transtrochanteric approach: Restricted weight bearing for ≥ 6 weeks
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
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)
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
Arthritis

Rheumatoid Arthritis

Movement and Exercise Guidelines (21.11, pg. 560)




Movement contraindications




High-impact cardiovascular exercise
Neck flexibility or strangthening in clients with history of neck instability
Movements outside the safe zone
Exercise contraindications





Improve function during daily activities
Improve general health
Protect affected joints
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
Arthritis

Common Modifications to Exercise

Common affected areas are cervical spine,
shoulders and wrists

Cervical spine


Shoulders


Avoid neck stretching or manual resistance in that area
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