NSCA CPT Chapter 21 – Clients With Orthopedic, Injury, and Rehabilitation Concerns
Chapter 21 – Clients With Orthopedic, Injury, and Rehabilitation Concerns

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    Chapter Objectives

    • Know the Common types of injury and orthopedic concerns.
    • Discuss the impact of injury on physical function.
    • Talk about the goals of the phases of tissue healing.
    • Discuss the trainer’s role in relation to specific orthopedic, injury, and rehabilitation concerns.

    Injury Classification

    Musculoskeletal injuries are determined based on many factors like onset and the type of tissue that is damaged.

    There is both macro and micro trauma. Macro trauma is an injury that suddenly and obviously occurs to the tissue. Micro trauma is more of an overuse injury that occurs over time. 

    The injury type is determined by the tissue that is involved. This could be a strain, sprain, or a fracture, and these can occur in a tendon, joint, or bone. 

    Common musculoskeletal injuries: 

    A muscle contusion is known as a bruise and happens when there is a forceful and sudden quick blow to the body. Hematomas are the result of the healing tissues that surround the muscle that is injured. The healing speed depends on the amount of damage and internal bleeding that has occurred in the area. Contusions may limit the injured muscles movement severely. 

    Muscle Strains are often the result of an abnormal muscle action leading to both stretching or tearing of some muscle fibers. Strains are given grades or degrees that are used to  indicate the injury severity. A first or second degree strain is a partial tear, and a third degree strain is a complete tear of the muscle tissue. Pain, strength limitations, and motion restrictions increase with increasing grades of strains. 

    Tendinopathy is used to describe the combination of both tendinitis and tendinosis. 

    Tendinitis is the inflammation of a tendon. This type of injury is often associated with swelling and pain surrounding the tendon that is injured. If this issue is not corrected or the tissue is not allowed to heal completely, then it could also lead to tendinosis.

    Tendinosis represents a histological definition of tendinitis and it involves a further breakdown and degeneration of the structures of the injured tendon. 

    A Ligament Sprain is a trauma that happens to the tissues that connect the bones and contribute to joint stability. Ligament sprains happen when excessive forces move the joint further than its anatomical limits and stretching the ligament. Ligament sprains are given grades just like the strains and these are also used to indicate the severity of the injury. With grade increases, we see more pain and more tenderness, swelling, joint instability, and loss of function. 

    Joint Dislocations occur when synovial joints moves beyond normal anatomical limits. Dislocations have two categories: subluxation and luxation. A subluxation is a partial displacement. A luxation is a complete displacement.

    Osteochondrosis refers to degenerative changes in the epiphyses of bones, particularly during periods of significant growth in children. 

    Osteoarthritis refers to the degeneration of articular or hyaline cartilage within a joint. This can occur in any joint but is most common in weight-bearing joints like the hip, knee, and ankle. 

    Bursitis is when the bursa becomes inflamed. Bursitis commonly occurs in the hip, knee, elbow, and shoulder and is usually accompanied by swelling, pain, and partial loss of function. 

    A bone fracture is a partial or complete disruption of a bone due to a direct blow.

    A bone stress fracture is a micro traumatic injury that may result from an abnormal muscle action, fatigue-related failure in the stress distribution across the bone, dramatic change in exercise or training ground surface, excessive training volume, or even both.

    Impact of Injury on Function

    Injuries will result in multiple impairments. These include range of motion being limited, lessened strength, balance, and coordinated movements. 

    Since injury creates changes in all tissues, range of motion is affected worse than others oftentimes. 

    How much strength is affected by injury will depend on the injury’s extent, the type of tissue or the area that is injured, the amount of time someone is immobilized by the injury, or a combination of these three things.

    Tissue Healing Following Injury

    Inflammation Phase

    This is the initial reaction by the body that is required for normal healing to occur. 

    After initial damage to the tissue, histamine and bradykinin are released to increase the blood flow and the capillary permeability. This essentially is the cause of edema.

    Decreased function may occur due to stimulation of sensory nerve fibers.

    This phase takes 2 – 3 days and possibly as long as 5 – 7 in more severe cases.

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    If not ended in a reasonable time, more healing is likely to not occur.

    Repair Phase

    Part of the first inflammatory phase may continue along with this phase starting 3 – 5 days after injury or 7 if its severe. There is no definitive end or beginning to the phases.

    This phase allows for the replacement of tissues that aren’t viable.

    The tissue that was damaged is regenerated. There are new capillaries and connective tissues formed in the area. Collagen is laid down as the framework for the repair. 

    Remodeling Phase

    This weaker tissue that is replaced during the previous repair phase is to be strengthened in this phase. The start is a transition from the repair phase. 

    Less collagen fibers are produced here, thus allowing what has been laid down to improve its structure, strength, and function.

    With proper loading, the tissues increase in strength and align along the lines of stress for their function.

    This can last 2 – 4 months after an injury, and for more extreme injuries it can be one year.

    Orthopedic Concerns and the Personal Trainer

    It is not the trainers job to determine the movement and exercise restrictions, but the trainers should determine the appropriate strategies based on the client’s restrictions and consultation with the client’s physician. 

    The cardinal signs for injury that should be monitored for are loss of range of motion and flexibility, lessened strength and function, and things like pain, swelling, warmth and color.

    An indication is any activity that will benefit the client.

    A contraindication is something that is not going to benefit he client and is thus inadvisable.

    A precaution is an activity that will be done while being supervised by a qualified personal trainer according to the limits and reproduction of symptoms.

    Appreciation for the physiology of healing will give the right selection of exercises and support a client’s full recovery.

    Low Back

    Low Back Pain

    This term refers to things such as disc dysfunctions, muscle strains, lumbar spinal stenosis, and spondylolisthesis.

    Movement and Exercise Guidelines

    The lower back responds really well with spinal stabilization exercise, posture correction, and also from flexibility training.

    For tightness or weakness, the common things to train are the hip flexors, hamstrings, and the hip lateral rotators.

    Balance work should be done for people who have hypermobility or instability.

    Restoring flexibility where it is needed will provide a lot of the help for lower back pain.

    Lumbar Disc Injury

    Movement and Exercise Guidelines

    Lumbar flexion is asked to be avoided most times with lumbar disc injury, and instead the client is asked to use extension.

    Flexibility is very important, but a lot of the basic stretches are avoided if they emphasize any form of lumbar flexion.

    Muscle Strain

    Movement and Exercise Guidelines

    Highly dependent on the muscle at question. 

    These muscles that are strained should be completely avoided when training at least for the initial healing and then introduced when pain subsides.

    Spondylolysis and Spondylolisthesis

    Movement and Exercise Guidelines

    Lumbar extension should be avoided in this case, and a focus needs to be put on strengthening the muscles surrounding the spine.


    The shoulder is very mobile and also requires muscular stability, thus the exercises done after injury will influence the client’s overall function greatly. It has the most mobility of the joint’s in the body, but because of this it also is the most susceptible to being injured.

    Impingement Syndrome

    Movement and Exercise Guidelines

    The exercises found on page 563 of the textbook are the recommended strengthening exercise as they don’t require much from the other muscles in the shoulder. 

    Focus is put on rotator cuff and scapular work. Also, rowing exercises for the upper back.

    Overhead work is done very cautiously.

    Anterior Instability

    Movement and Exercise Guidelines

    For anterior instability, the similar rules apply from the impingement syndrome section.

    The combined external rotation with more than 90 degrees of abduction should be avoided.

    Rotator Cuff Repair

    Movement and Exercise Guidelines

    Rotator cuff strengthening exercises should be started in 4 – 6 weeks after surgery.

    Overhead movements with weight should be completely avoided.

    It is also important to avoid any painful exercises and early quick eccentric actions.


    Ankle sprains are the most common injury in all of sports.

    Movement and Exercise Guidelines

    Pain and inflammation is the priority to control when first injured. This allows for proper ligament healing.

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    Small stress is important to introduce as soon as possible, as it will heal the tissue more completely.

    It is important to work balance, as it reduces the risk of repeat injuries and it is lost quite quickly when recovering.


    Anterior Knee Pain

    Movement and Exercise Guidelines

    Education of proper materials to work out on or the right ways to do movement comes first with this.

    There should be added unilateral balance tests and a target put on increasing the strength of the hip.

    Exercises to be avoided are the full squat, the full lunge, stair steppers with larger steps, and the end motion of the leg extension. All of these should be slightly modified to not do the full range of motion.

    Anterior Cruciate Ligament Reconstruction

    Movement and Exercise Guidelines

    Exercise and training should wait until the client is 4 – 6 weeks out of surgery. It can even be 3 – 4 months for some surgeries.

    Open chain knee movements that are less than 45 degrees of knee flexion are avoided.

    Another big one to avoid is the end of the range of motion of the leg extension.

    We use both closed and open kinetic chain exercises to train these individuals. The range of motion is just limited.

    Total Knee Arthroplasty

    Movement and Exercise Guidelines

    Closed chain movements with more than 100 degrees of knee flexion and kneeling are both avoided. 

    The exercises we specifically avoid are the full squat and the full lunge.

    Rehab begins immediately after surgery and the focus is on range of motion.


    Hip Arthroscopy 

    Movement and Exercise Guidelines

    This has a relatively quick return to activity compared to other things.

    Return to activity is about 16 – 32 weeks, but also determined by the procedure itself.

    Unilateral and bilateral balance is stressed in the training.

    Total Hip Arthroplasty

    Movement and Exercise Guidelines

    There should be no forceful hip flexion and no hip abduction and rotation in early recovery.

    As far as limiting exercises, ballistic and forced stretching needs to not be done.

    The most common type of exercise to do for recovery is aquatic walking.



    Movement and Exercise Guidelines

    High impact activities are avoided for the most part along with limiting exercises like running, snow skiing, or jogging to name a few.

    Exercises that are recommended are things like biking, stair stepping, using the elliptical, and also aquatics.

    Rheumatoid Arthritis 

    Movement and Exercise Guidelines

    We avoid high impact exercise here too, along with neck flexibility or strengthening for someone who has a history of neck instability, and any movement outside of someone’s safe zone.

    Running and jogging, upper trapezius stretching, manually resisted neck strengthening, and behind the back shoulder pressing is strictly avoided.

    It is recommended to work out at about 60 – 80% of max heart rate in similar exercises to the osteoarthritis recommendations.

    Range of motion and flexibility is important.

    Isometric exercise is done for the unstable joint.

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    NSCA CPT Chapter 21 – Clients With Orthopedic, Injury, and Rehabilitation Concerns 1
    NSCA CPT Chapter 21 – Clients With Orthopedic, Injury, and Rehabilitation Concerns 2
    NSCA CPT Chapter 21 – Clients With Orthopedic, Injury, and Rehabilitation Concerns 3

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