1. ACE Personal Trainer Manual 5th Edition
Chapter 15: Common Musculoskeletal Injuries and Implications for Exercise
Lesson 15.1

2. LEARNING OBJECTIVES
After completing this session, you will be able to:
Identify the difference between muscle strains and ligament sprains and the grading system of each
Understand the main overuse conditions and how cartilage damage and bone fractures can occur
Discuss the healing process phases and recall signs and symptoms of inflammation
Explain the conservative management of common musculoskeletal injuries
Discuss the following injuries and recommend appropriate exercise programming:
Shoulder strain/sprain
Rotator cuff injuries
Elbow tendinitis
Carpal tunnel syndrome
Greater trochanteric bursitis

3. MUSCLE STRAINS
Microscopic tears of the muscle fibers cause swelling, discoloration (ecchymosis), or loss of function.
Hamstring group
Risk factors – poor flexibility, poor posture, muscle imbalance, improper warm-up, and training errors
Groin
Risk factors – muscle imbalance between the hip adductors and abductors
Gastrocnemius and soleus
Risk factors – muscle fatigue, fluid and electrolyte depletion, forced knee extension during dorsiflexion, and forced dorsiflexion during knee extension

4. MUSCLE STRAINS GRADING SYSTEM

5. LIGAMENT SPRAINS
A joint injury that results in stretching or tearing of the stabilizing connecting tissues causing immediate pain, swelling, instability, decreased range of motion (ROM), and a loss of function
Sprains occur most often with trauma, such as falling or during contact sports:
Ankle
Knee
ACL injuries – decelerating while twisting, pivoting, and sudden stopping or cutting motions
MCL injuries – impact to the outer knee with no twisting involved; or damaged at the same time as the ACL
Thumb or finger
Shoulder

6. LIGAMENT SPRAINS GRADING SYSTEM

7. OVERUSE CONDITIONS Tendinitis – inflammation of the tendon:
Commonly occurs in the shoulders, elbows, knees, and ankles
Inflammatory response from too much demand on a tendon caused by beginning new activities or programs too quickly
Bursitis – inflammation of the bursa sac:
Commonly affects the shoulders, hips, and knees
Occurs from acute trauma, repetitive stress, muscle imbalance, or muscle tightness on top of the bursa
Fasciitis – inflammation of the connective tissue called fascia:
Commonly occurs in the bottom and back of the foot
Note: Some experts are now referring to tendinitis as tendinopathy.

8. CARTILAGE DAMAGE
Damage to the joint surface of the knee involves damage to both:
Hyaline cartilage – covers the articular surfaces of bones
Menisci cartilage – in between the femur and tibia
Meniscal injuries occur with:
Loading or twisting of the joint and often with ACL or MCL tears
Degeneration – degenerative joints may lead to acute tears in older adults
Signs and symptoms of meniscal tears:
Joint pain
Swelling
Muscle weakness
Stiffness
Giving way
Locking, clicking, or popping

9. CARTILAGE DAMAGE
Chondromalacia – a softening or wearing away of the cartilage under the patella:
May occur from the patella not properly tracking
Has been associated with:
Improper training methods
Sudden changes in training surface
Lower-extremity muscle weakness or tightness
Foot overpronation
Signs and symptoms:
Pain and inflammation
Pain behind the patella during activity
Pain that increases while walking up or down stairs

10. BONE FRACTURES Low-impact trauma: High-impact trauma:
A short fall on a level surface resulting in a minor fracture
Repeated microtrauma to a bone region resulting in a stress fracture
Symptoms include:
Progressive pain that is worse with weightbearing activity
Focal pain
Pain at rest
Local swelling
High-impact trauma:
Occurs in motor vehicle accidents or during high-impact sports
Requires immediate medical attention and is often disabling
Pathological fractures – caused by infection, cancer, osteoporosis, or other medical conditions that can weaken bones

11. TISSUE REACTION TO HEALING
Inflammatory phase – can typically last for up to 6 days
The healing process begins and the injured area is immobilized
Blood flow increases to bring in oxygen and nutrients to rebuild the damaged tissue
Fibroblastic/proliferation phase – begins around day 3 and lasts until around day 21
The wound fills with collagen and other cells, forming a scar
Within 2 to 3 weeks, the wound can resist normal stresses, but strength continues to build for several months
Maturation/remodeling phase – begins around day 21 lasting for up to 2 years
Remodeling of the scar, rebuilding of bone, and/or restrengthening of the tissue
Exercise progression must always be done cautiously when working with individuals recovering from a musculoskeletal injury.

12. SIGNS AND SYMPTOMS OF INFLAMMATION
It is important to be aware of these signs, especially for clients who are post-injury or post-surgery:
Pain
Redness
Swelling
Warmth
Loss of function
The goal is to give a client a challenging exercise program that will not cause further damage to an injured area.

13. MANAGING MUSCULOSKELETAL INJURIES
Pre-existing injuries:
Determine if the client can exercise or if they must be cleared by a physician
The client may be able to participate in a modified program using the non-injured body parts
Acute injuries:
Must be handled quickly with caution
Refer to appropriate medical professionals
Perform RICE:
R – Rest or restricted activity
I – Ice applied hourly for 10–20 minutes
C – Compression wrap the area to minimize swelling
E – Elevate the injured area 6–10 inches above the heart to control swelling
If a client has a pre-existing condition, his or her exercise program may need to be modified. The client should be monitored for any changes in symptoms, including pain. The following are some commonly reported symptoms of post-injury/post-surgery overtraining (Brotzman & Manske, 2011):
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

14. FLEXIBILITY AND MUSCULOSKELETAL INJURIES
Decreased flexibility is associated with various injuries, including:
Muscle strains
Overuse conditions
When a muscle becomes shortened and inflexible, it cannot lengthen appropriately or generate adequate force.
A personal trainer can develop a stretching program to:
Address inflexibility
Help prevent further injury
The following are contraindications to stretching that need to be considered to prevent injury:
A fracture site that is healing
Acute soft-tissue injury
Post-surgical conditions
Joint hypermobility
An area of infection
A hematoma or other indication of trauma
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
If a client presents with any type of contraindication, the personal trainer should get further clearance from a medical professional prior to beginning a stretching routine.

15. CONSERVATIVE MANAGEMENT

16. UPPER- AND LOWER-EXTREMITY INJURIES
Upper-extremity injuries:
Shoulder strain/sprain
Rotator cuff injuries
Elbow tendinitis
Carpal tunnel
Lower-extremity injuries:
Greater trochanteric bursitis
Iliotibial band syndrome
Patellofemoral pain syndrome
Infrapatellar tendinitis
Shin splints
Ankle sprains
Achilles tendinitis
Plantar fasciitis

17. SHOULDER STRAIN AND SPRAIN
Soft-tissue structures (bursa and rotator cuff tendons) get abnormally stretched or compressed.
Results from an impingement secondary to the compression and ends up as tendinitis
Can eventually lead to rotator cuff tears if not managed properly
Signs and symptoms:
Local pain that radiates down the arm
Swelling, tenderness, pain, and stiffness
Aggravated by lifting or reaching overhead or across the body
Management:
Conservative management – Table 15-3
Avoid aggravating movements (overhead, across, or behind the body)
Strains/sprains are common in the shoulder as a result of this joint’s significant mobility and the sacrifice of stability to achieve it.

18. EXERCISE PROGRAMMING FOR SHOULDER STRAIN AND SPRAIN
Improve posture and body positioning
Regain strength in the scapular stabilizers and rotator cuff muscles
Restore proper flexibility of the shoulder complex
Modify exercises as necessary to prevent further injury
Overhead activities:
Will often need to be modified to avoid pain and further injury
Modify the movement ROM (as to not fully extend arms)
Use the scapular plane:
The shoulder is positioned 30 degrees anterior of the frontal plane.

19. ROTATOR CUFF INJURIES
Acute – related to trauma such as falling on the shoulder or raising the arm against overwhelming resistance
Chronic – a result of a degeneration and gradual worsening of pain and weakness
Management:
The client should see a physician or physical therapist
Restriction from performing certain activities
Surgery may be indicated
Signs and symptoms:
A feeling of sudden “tearing” followed by pain and a loss of motion
Pain when reaching overhead or behind the back
Pain at night or after activity

20. EXERCISE PROGRAMMING AFTER ROTATOR CUFF REPAIR
Immobilization for six to eight weeks to allow the repair to heal
Passive ROM only to prevent re-tearing
Potentially cleared for activity after approximately 16 weeks or discharged from physical therapy
The personal trainer should:
Obtain specific guidelines for what “should” and “should not” be done
Be cautious with specific shoulder positions to avoid strain in the healing tissue, such as limiting:
Performing overhead activities
Keeping the arm straight during exercise (keep elbows bent for less torque)
Modify exercises as necessary to prevent future injury

21. ELBOW TENDINITIS Lateral epicondylitis – “tennis elbow”
Overuse or repetitive trauma injury of the wrist extensor muscle tendons near the origin on the lateral epicondyle of the humerus
Medial epicondylitis – “golfer’s elbow”
Overuse or repetitive trauma injury of the wrist flexor muscle tendons near the origin on the medial epicondyle
Signs and symptoms:
Nagging elbow pain during aggravating activities
Management:
Conservative management – Table 15-3
Avoid aggravating movements that include repetitive elbow and wrist flexion/extension activities

22. EXERCISE PROGRAMMING FOR ELBOW TENDINITIS
Emphasize client education to avoid aggravating activities
Improve posture and body positioning
Regain strength and flexibility of the flexor/pronator and extensor/supinator muscles in the wrist and elbow
The client may be prescribed a wrist or elbow splint
Modify exercises as necessary to prevent further injury
Additionally, clients should:
Avoid high-repetition activity (e.g., 15–20 repetitions) at the elbow and wrist
Begin dumbbell biceps and wrist curls with low weight and repetitions
Be cautious with full elbow extension (i.e., locking the elbow) when performing shoulder exercises to prevent excessive loading

23. CARPAL TUNNEL SYNDROME
Repetitive wrist and finger flexion when the flexor tendons are strained
Results in a narrowing of the carpal tunnel due to inflammation and median nerve compression
Signs and symptoms:
Gradual pain, weakness, or numbness in the radial three-and-a-half digits and thumb
As the condition progresses, specific symptoms occur:
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
Management:
Conservative management – Table 15-3
Wrist splints during activity, or surgical options

24. EXERCISE PROGRAMMING FOR CARPAL TUNNEL SYNDROME
Emphasize client education to avoid aggravating activities.
Improve posture and body positioning
Regain strength and flexibility of the elbow, wrist, and finger flexors and extensors.
The client may be prescribed a wrist splint.
Modify exercises as necessary to prevent further injury.
Additionally, clients should:
Avoid movements that involve full wrist flexion or extension, which can further compress the carpal tunnel and increasing symptoms
Focus on exercising in the mid-range of flexion or extension

25. SUMMARY
All personal trainers work with clients who have sustained, or will sustain, an injury in the course of their activities.
Learning to recognize the signs and symptoms of inflammation and knowing the proper steps in acute injury care can allow the trainer to help the injured client recover more quickly.
All trainers should receive as much training as is available in first aid and injury recognition.
An understanding of how the body reacts to injury and resulting repair will help clients plan an appropriate program.