ACE Personal Trainer
Manual, 4th edition
Chapter 15:
Common Musculoskeletal Injuries
and Implications for Exercise
1
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
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 sidestepping.
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
(degeneration of the cartilage of
the knee).
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/postsurgery 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 earlyintervention 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 (loose joint)
–
An area of infection
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
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 in
physical therapy in a safe, progressive manner.
 Performing overhead activities or keeping the
arm straight during exercise should be limited.
 Exercises with the elbows bent will create
less 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
–

Medial epicondylitis
–

Repetitive-trauma injury of the wrist flexor muscle tendons near their origin on the medial
epicondyle
Signs and symptoms
–

Repetitive-trauma injury of the wrist extensor muscle tendons near their origin on the lateral
epicondyle
Nagging elbow pain at the lateral or
medial epicondyle
Medical management
–
Conservative management for
musculoskeletal 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, and
middle fingers
–
Long-standing effects may include atrophy of the thumb
side of the hand, loss of sensations, and paresthesias (numbness).
Medical management
–
Conservative management for musculoskeletal injuries,
with the exception of cortisone injections to treat inflammation
–
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 on
restoring proper strength
throughout the hip, knee,
and ankle with closed-chain
movements.
 Open-chain knee activity
such as leg extensions
should be done with caution.
http://www.youtube.com/watch?v=9AZHU_WEypI
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 the
distal posterior medial tibia.
–
Anterior shin splint sufferers complain of the same
type 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.
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 be
medial swelling with tenderness
over 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 (e.g., flat feet)
• Pes cavus (e.g., high arch)
– 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 (i.e., treatment)
– 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.
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