ACE PERSONAL TRAINER MANUAL 5 TH EDITION Chapter

ACE PERSONAL TRAINER MANUAL 5 TH EDITION Chapter 15: Common Musculoskeletal Injuries and Implications for Exercise Lesson 15. 2

LEARNING OBJECTIVES • After completing this session, you will be able to: ü Discuss the following injuries and recommend appropriate exercise programming: o o o o Greater trochanteric bursitis Iliotibial band syndrome Patellofemoral pain syndrome Infrapatellar tendinitis Shin splints Ankle sprains Achilles tendinitis Plantar fasciitis • Understand the importance of HIPAA and keeping thorough exercise records, reports, and client information © 2014 ACE

PROPER FOOTWEAR • Personal trainers can offer some basic guidelines to help their clients purchase appropriate footwear for their activities: ü Decide what type of shoe is needed for the specific activity: o Running, walking, multipurpose, studio classes, etc. ü Recommend a specialty athletic shoe store, as their sales staffs are more likely to be knowledgeable about ensuring a proper fit ü Wear socks made with synthetic fibers such as acrylic, polyester, or Coolmax for blister prevention ü Be aware of when shoes need to be replaced: o Shoes eventually lose cushioning and no longer absorb impact, which puts a client at risk of ankle, shin, and knee injuries o Look at the wear patterns as a good indicator for replacement © 2014 ACE

GREATER TROCHANTERIC BURSITIS • Painful inflammation of the bursa between the femur and the gluteus medium tendon/proximal iliotibial band complex • Due to acute incident (falling, contact sports) or repetitive trauma (friction from running, cycling, or kickboxing) • Signs and symptoms: ü Trochanter pain and/or parasthesias down the iliotibial tract to the lateral knee ü Limping due to pain and weakness, resulting in decreased muscle length, strength, and myofascial tightness © 2014 ACE

EXERCISE PROGRAMMING FOR GREATER TROCHANTERIC BURSITIS • Emphasize proper training techniques, equipment (e. g. , footwear), and early injury recognition • Regain flexibility and strength at the hip • Stretching to ensure proper lower-extremity mobility: ü Iliotibial band complex ü Hamstrings and quadriceps ü Strengthening the gluteals and deeper hip rotator muscles ü Proper gait techniques in walking and running ü Modify exercises as necessary to prevent further injury • Additionally, clients should: ü Avoid side-lying positions that compress the lateral hip ü Limit higher-loading activity such as squats or lunges as tolerated ü Try aquatic exercise to provide a gradual return to landbased exercises © 2014 ACE

ILIOTIBIAL BAND SYNDROME • Repetitive overuse condition that occurs when the distal portion of the iliotibial (IT) band rubs against the lateral femoral epicondyle • Risk factors: ü Overtraining ü Improper footwear ü Changes in running surface ü Muscle imbalance ü Structural abnormalities ü Failure to stretch correctly © 2014 ACE

ILIOTIBIAL BAND SYNDROME • Signs and symptoms: ü Gradual onset of tightness, burning, or sharp pain at the lateral aspect of the knee ü Snapping, popping, or pain at the lateral knee when flexed and extended ü May be aggravated by repetitive activities, such as running or cycling • Management: ü Conservative management (Table 15 -3) ü Individuals could use an assistive device, such as a cane © 2014 ACE

EXERCISE PROGRAMMING FOR ILIOTIBIAL BAND SYNDROME • A slow return to activity is recommended • Emphasize proper training techniques, equipment (e. g. , footwear), and early injury recognition • Focus on regaining flexibility and strength at the hip and lateral thigh • Modify exercises as necessary to prevent further injury • Additionally, clients should: ü Introduce higher-loading activities such as lunges or squats at a slower pace ü Lunges and squats limited to 45 degrees of knee flexion can be introduced with a progression to 90 degrees and beyond, if tolerated ü Try aquatic exercise due to buoyancy and low-impact nature © 2014 ACE

PATELLOFEMORAL PAIN SYNDROME • Known as “runner’s knee” and classified into three categories: ü Overuse – repetitive loading causes abnormal stress to the knee joint, leading to pain and dysfunction ü Biomechanical abnormalities – can alter the tracking of the patella and/or increase patellofemoral joint stress o Both pes planus (flat foot) and pes cavus (high arches) alter the alignment of the knee ü Muscle dysfunction – causing abnormal tracking of the patella • Tightness in the IT band complex • Hamstring and gastrocnemius/soleus complex tightness • Quadriceps, hip abductor, and external rotator weakness © 2014 ACE

PATELLOFEMORAL PAIN SYNDROME • Signs and symptoms: ü Pain with running, ascending or descending stairs, or prolonged sitting ü “Achy” pain under the patella ü Stiffness, giving way, clicking, or a popping sensation • Management: ü Avoiding aggravating activities ü Modifying training variables ü Proper footwear ü Patellar taping or knee bracing ü Foot orthotics ü Oral anti-inflammatory medication ü Modalities (e. g. , ice or heat) © 2014 ACE

EXERCISE PROGRAMMING FOR PATELLOFEMORAL PAIN SYNDROME • Stretch the IT band complex and utilize myofascial release (e. g. , on a foam roller) • Stretch the hamstrings and calves to restore muscle-length balance • Strengthen the hip, knee, and ankle: ü Closed-chain exercises such as squats and lunges may be beneficial ü Limit open-chain knee exercises due to abnormal stress on the patella ü Modify exercises as necessary to prevent further injury • Additionally, clients should: ü Exercise in the mid-range (i. e. , 45 degrees) of closed-chain activities for comfort • Limit open-chain knee activity such as leg extensions: ü Try a straight-leg raise in a sitting or supine position to challenge the quadriceps group without imposing extra stress on the patella © 2014 ACE

INFRAPATELLAR TENDINITIS • Known as “jumper’s knee” • Overuse syndrome characterized by inflammation of the patellar tendon at the insertion into the distal patella and proximal tibia • Potential causes include: ü ü Improper training methods Sudden change in training surface Lower-extremity inflexibility Muscle imbalance • Signs and symptoms: ü Pain at the distal kneecap into the infrapatellar tendon when running, using stairs, squatting, or prolonged sitting © 2014 ACE

EXERCISE PROGRAMMING FOR INFRAPATELLAR TENDINITIS • Stretching and myofascial release (e. g. , foam roller) of: ü Quadriceps ü IT band ü Hamstrings ü Calves • Restore strength throughout the hip, knee, and ankle • Modify exercises as necessary to prevent further injury • Additionally, clients should: ü Return slowly to loading activities to further reduce the chance of re-injury ü Limit high-impact activities such as running or plyometrics until tolerated © 2014 ACE

SHIN SPLINTS • A general term used to describe exertional leg pain; classified into two categories: ü Medial tibial stress syndrome (MTSS); also called posterior shin splints o Overuse injury o Periostitis o Most common in runners, dancers, and military personnel ü Anterior shin splints o Pain occurring in the anterior compartment of the leg o Common in runners and military personnel ü Signs and symptoms of MTSS: o A “dull ache” along the distal two-thirds of the posterior medial tibia ü Signs and symptoms of anterior shin splints: o A “dull ache” along the distal anterior shin o Pain is elicited by initial activity and diminishes as activity continues o Pain may return hours after activity © 2014 ACE

EXERCISE PROGRAMMING FOR SHIN SPLINTS • Rest, modified activities, and cross-training are recommended for symptom relief • Slowly introduce full unrestricted activity without exacerbating the symptoms • Stretch the entire lower body, plus specific calf and soleus stretches, to address muscle-length deficits that may affect the foot and ankle • Strengthen the lower body to address muscular deficits and imbalances • Modify exercises as necessary to prevent further injury • Additionally, clients should: ü Gradually return to activity; too much too soon can re-aggravate symptoms ü Minimize an extreme change in surface, such as from pavement to sand, to avoid further stress © 2014 ACE

ANKLE SPRAINS • Lateral or inversion sprains: ü Most common – involve the lateral ankle ligaments ü Mechanism of injury – typically inversion with a plantarflexed foot • Medial or eversion sprains: ü Relatively rare – involve the medial deltoid ligament ü Results from forced dorsiflexion and eversion of the ankle • Signs and symptoms: ü Lateral sprains – the individual can recall the injury and may report a “pop” or “tearing” sound ü Medial sprains – the individual is unable to recall the injury, but can reproduce the discomfort by dorsiflexing and everting the ankle • Refer to grading system for ligament sprains © 2014 ACE

EXERCISE PROGRAMMING FOR ANKLE SPRAINS • Focus on restoring proper proprioception, flexibility, balance, and strength: ü General stretches for the lower extremity, specifically the calf muscles, due to tightness from immobilization • Lower-leg strength, specifically the peroneal muscles, for prevention of re-injury: ü Side stepping with a band or ankle eversion with resistive bands ü Modify exercises as necessary to prevent further injury • Clients may lack stability with side-to-side and multidirectional motions and should progress in the following order: ü Straight-plane motions such as forward running ü Side-to-side motions such as sidestepping ü Multidirectional motions such as carioca © 2014 ACE

ACHILLES TENDINITIS • May lead to a partial or complete tear of the Achilles tendon if not addressed • Various factors may lead to acute tendon trauma, overuse, and chronic injury: ü ü ü ü ü Age (45+ years at higher risk) Pes cavus or pes planus Leg-length discrepancies Lateral ankle instability Errors in training Prior injuries Poor footwear Muscle weakness Poor flexibility • Signs and symptoms: ü Complaints of pain above the tendon insertion into the calcaneus ü Initial morning pain that is “sharp/burning” and increases with vigorous activity © 2014 ACE

EXERCISE PROGRAMMING FOR ACHILLES TENDINITIS • Emphasize client education and aim for a gradual, pain-free return to activity • Restore proper length to the calf muscles to reduce strain but avoid overstretching • Avoid overexertion to lessen irritation to the Achilles tendon • Use controlled eccentric strengthening of the calf complex to reduce pain and improve strength • Modify exercises as necessary to prevent further injury • Additionally, clients should avoid excessive pronation or supination when stretching the calf – keep the foot position neutral © 2014 ACE

PLANTAR FASCIITIS • An inflammatory condition of the plantar aponeurosis (fascia) of the foot • Plantar fasciitis can be seen throughout the plantar surface of the foot • Several factors are associated: ü ü ü Pes planus and pes cavus Overtraining Improper footwear Obesity Unyielding surfaces • Signs and symptoms: ü Complaints of pain in the medial side of the heel ü Pain is most noticeable with initial steps after a period of inactivity (i. e. , getting out of bed) and usually lessens with increasing levels of activity during the day ü Pain may worsen toward the end of the day © 2014 ACE

EXERCISE PROGRAMMING FOR PLANTAR FASCIITIS • Integrate specific foot exercises into the client’s general fitness program without excessively loading the foot • Stretch the gastrocnemius, soleus, and plantar fascia to relieve symptoms • Self–myofascial release techniques to enhance ROM in the plantar fascia • Strengthen the foot’s intrinsic muscles to improve arch stability and decrease the stresses imposed across the plantar fascia • Strengthen the gastrocnemius, soleus, peroneals, tibialis anterior, and tibialis posterior muscles to improve strength at the ankle • Modify exercises as necessary to prevent further injury • Additionally, clients should include stretches to isolate the plantar fascia, such as bending the toes with the hands or against a wall. © 2014 ACE

RECOVERING FROM AN INJURY Working with clients who are recovering from an injury is challenging for many personal trainers because workouts must be modified to suit individual needs. For a specific injury in this chapter, consider program modifications that would help the client safely engage in exercise after he or she has received medical clearance for physical activity. © 2014 ACE

RECORD KEEPING • Incident report • Client safety is most important: ü First aid or EMS activation • A formal, written account of the incident must be documented • The trainer should keep his or her own account of what occurred and maintain any pertinent documentation • Correspondence: ü Protection of the client’s personal information is critical ü Health Insurance Portability and Accountability Act – HIPAA ü All medical records are confidential • A personal trainer must obtain written permission prior to discussing information with an outside party © 2014 ACE

RECORD KEEPING • Keeping current and accurate records for every client is essential. • Medical history: ü Past and present medical conditions and current medications ü Update each client’s records every three months, including medical clearances ü Document details of the client’s present conditions, especially prior to beginning an exercise program • Exercise record: ü Stay current with specific notations for any changes, such as a new onset of “pain” ü Write down important details of every session © 2014 ACE

SUMMARY • The key when working with clients who have sustained an injury is to avoid exercises that aggravate pre-existing conditions. • The ability to design a program for a client that will avoid injury is critical to the success of the program. • It is also important for trainers to know the common injuries associated with physical activity. • Doing so will increase one’s confidence in dealing with clients in these types of situations. © 2014 ACE