NSCA CPT 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 the injury on physical function.
• Talk about the goals of the phases of tissue healing.
• Discuss the trainer’s role in 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 fracture, which 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 often result from an abnormal muscle action leading to stretching or tearing of some muscle fibers. Strains are given grades or degrees that are used to indicate injury severity. A first or second-degree strain is a partial tear, and a third-degree strain is a complete muscle tissue tear. 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 injured tendon. 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 occur when excessive forces move the joint beyond its anatomical limits and stretch 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, tenderness, swelling, joint instability, and loss of function. 

Joint Dislocations occur when synovial joints move beyond normal anatomical limits. Dislocations have two categories: subluxation and luxation. Subluxation is a partial displacement. 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 a limited range of motion, lessened strength, balance, and coordinated movements. 

Since injury creates changes in all tissues, the 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 injured area, the amount of time the injury immobilizes someone, or a combination of these three things.

Tissue Healing Following Injury

Inflammation Phase

This is the body’s initial reaction required for normal healing to occur. 

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

A decreased function may occur due to the stimulation of sensory nerve fibers.

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

If not ended in a reasonable time, more healing will likely 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 it’s 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. 

Fewer 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; it can be one year for more extreme injuries.

Orthopedic Concerns and the Personal Trainer

Determining the movement and exercise restrictions is not the trainer’s job. Still, the trainers should determine the appropriate strategies based on the client’s restrictions and consultation with the client’s physician. 

The cardinal signs of an 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 will not benefit the 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 well to spinal stabilization exercises, posture correction, and flexibility training.

The common things to train for tightness or weakness are the hip flexors, hamstrings, and 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 help for lower back pain.

Lumbar Disc Injury

Movement and Exercise Guidelines

Lumbar flexion is often avoided with a lumbar disc injury, and instead, the client is asked to use an extension.

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

Muscle Strain

Movement and Exercise Guidelines

Highly dependent on the muscle in question. 

Strained muscles should be completely avoided when training, at least for the initial healing, and then introduced when the pain subsides.

Spondylolysis and Spondylolisthesis

Movement and Exercise Guidelines

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

Shoulder

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

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 the 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, 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.

Avoiding painful exercises and early, quick eccentric actions is also important.

Ankle

Ankle sprains are the most common injury in all sports.

Movement and Exercise Guidelines

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

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

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

Knee

Anterior Knee Pain

Movement and Exercise Guidelines

Education on proper materials to work out or the right movement methods 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 not to 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 take 3 – 4 months for some surgeries.

Open chain knee movements under 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 focuses on the range of motion.

Hip

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, which is also determined by the procedure.

Unilateral and bilateral balance is stressed in training.

Total Hip Arthroplasty

Movement and Exercise Guidelines

In early recovery, there should be no forceful hip flexion and no hip abduction and rotation.

Regarding limiting exercises, ballistic and forced stretching need not be done.

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

Arthritis

Osteoarthritis

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 with a history of neck instability and any movement outside someone’s safe zone.

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

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

Range of motion and flexibility is important.

Isometric exercise is done for the unstable joint.

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