Chapter 21b Clients with Orthopedic, Injury and Rehabilitation Concerns

NSCA’s Essentials

Shoulder Because of the type of joint and area of the shoulder, it

is a structure that can be susceptible to injury The following sections discuss indicated and

contraindicated exercises, strategies, etc. for clients with shoulder issues

The trunk and hips are vital to shoulder function, the legs provide 51-55% of the total kinetic energy and total force for overhead activities.

A program for shoulder health should include strengthening exercises for the hip rotators, hip abductors, and hip extensors, as well as the abdominal and low back stabilizing muscles

Shoulder Shoulder Impingement Syndrome

Essentially is pinching of the supraspinatus (part of the rotator cuff…remember SITS), the long head of the biceps or the bursa underneath the acromial arch (subacromial bursa)

Can be treated conservatively or with surgical procedures

Causes for surgical procedures include: Abnormalities of bone (example…a hook acromion

process that compresses structures)

Shoulder Factors that may be altered

Muscular imbalances ROM (if limited) Poor posture Poor scapula control Poor and improper exercise technique Overuse issues of the shoulder (overhead

activities…what are some examples of overhead activities that could contribute to this problem?)

Shoulder Movement and Exercise Guidelines

See Figures 21.5 to 21.9 (pg. 545-546) (series of exercises recommended for rotator cuff activation with minimal use of other muscle groups)

These are very common exercises use in non-surgical and surgical rehab programs

The rotator cuff muscles have a primary function in endurance so these exercises are performed typically in this manner:

Light weights (really no more than 4 or so pounds) High reps (15-20)

Shoulder The other great thing about these exercises

is that they put the shoulder in a safe position

This position is neutral environments below 90 degrees of elevation with the arm in a forward position relative to the body (think anterior to frontal plane…remember frontal plane…abduction/adduction)

These exercises are great for pain free exercises and decreasing chances of shoulder impingement

Shoulder Clients need to concentrate on strengthening

rotator cuff and scapula muscles For example…rowing exercising (seat row, etc.) are

great for increasing rhomboid and trapezius strength Overhead pressing activities and bench press should

be used cautiously (decline bench may be better = inside safe zone)

Upright row should be used cautiously as well (rowing elbows too high can aggravate the impingement type pain)

Some cardio equipment may be a problem as well (versa-climbers place the arm above the head and could cause impingement aggravation)

Racket sports should be used with caution as serving overhead or smashing a shot from high above and down could cause aggravation

Shoulder Anterior Instability

This is when the glenohumeral joint moves too far forward, which then can cause injury such dislocation

Following dislocation, re-dislocation is a high possibility (90% in young active individuals, 30-50% in middle aged individuals…why the difference?)

This is a difficult rehabilitation areas due to the laxity and instability of this area structurally

Shoulder Movement and Exercise Guidelines

Indications for strengthening instability are similar to impingement (strengthen rotator cuff and scapula muscles)

Use similar exercises like in 21.5-9 (pg. 545-546) Movements that are contraindicated and could lead to

dislocation: Greater than 90 degrees of elevation Hands and arms behind plane of shoulder

Follow safe zone guidelines: Activities below 90 degrees of elevation of the shoulder (see

figure 21.10 pg. 548) Arms anterior to frontal plane of the body (see figure. 21.10

pg. 548)

Shoulder

Rotator Cuff Repair Carried out when damage to the

rotator cuff tendons-most often the tendon of the supraspinatus muscle-occurs

These tears cause altered joint mechanics and usually require arthroscopic surgery.

Two days to six weeks in a sling, but surgeon decides on recovery time

Shoulder Ultimately clients may choose a

conservative approach based on exercise or choose surgery

Allow for exercise modifications regardless of choice to protect structures

Even with treatment completed clients should try to remain in safe zone in activities Exercises outside of the safe zone are

contraindicated

Shoulder Movement and Exercise Guidelines

Often discharged from formal rehabilitation three to four months following the surgery

Contraindicated exercises listed in table 21.4, pg. 547 Contraindicated exercises

High resistance training and low-repetition upper extremity strengthening

Exercises outside of the safe zone Examples of exercises:

Shoulder press Bench press Behind the neck lat pulldown Racket sports swimming

Shoulder Movement and Exercise Guidelines

Exercises 21.5-9 are also applied for strengthening after rotator cuff repair, but usually not until four to six weeks after surgery

Table 21.4 provide contraindicated activities Overhead lifting and push ups/bench press are

contraindicated (can result in overload of cuff) Lower body aerobic exercises are well suited

(walking, running, etc.)

Shoulder Conditions Requiring Shoulder Exercise

Modification Rotator Cuff Repair Rotator Cuff Tendonitis Glenohumeral joint instability (prior

dislocation, etc.) Acromioclavicular joint injury (separation) Glenohumeral joint osteoarthritis) See Table 21.5 (pg. 550) for “Shoulder

Exercise Modifications”

Shoulder

So…let’s take some time and go through the pictured exercises on pg. 545-546 of your text and Table 21.5 on pg 550

Let’s get to it!

Knee Anterior Knee Pain

Common knee issues include: Chondromalacia Iliotibial band friction syndrome Irritated plica Patellar tendonitis

Client with these issues commonly describe pain from prolonged sitting and walking up and own stairs

Lots of times diagnosis is based upon overuse, biomechanical issues, and muscular imbalances

Rehabilitation focuses on reducing pain and inflammation, correcting biomechanical faults and optimizing tissue function

Knee Movement Exercise Guidelines

Increase quadriceps strength as it improve functional activities (walking up and down stairs) and increasing patellofemoral function and reduces knee pain

Deep squats, closed kinetic chain activities or exercises requiring knee flexion more than 90 degrees should be used cautiously

Aerobic activities that require deep squatting or lunging should be avoided (contraindicated)

Cycling or water based activities can be used to maintain client’s aerobic base

It is common for anterior knee pain clients to use some form of taping or patellar support

Knee

Anterior Knee Pain Movement contraindications (table 21.7, pg. 553)

Closed chain knee movements with > 90 degrees of knee flexion

Open chain knee movements 0 to 30 degrees of knee flexion

Exercise contraindications Closed chain: full squat, full lunge Open chain: end range leg extension, stair stepper with

large steps Exercise indications

Closed chain: ¼ to ½ squat and leg press Open chain: partial lunge; leg curl, stair stepper with short,

choppy steps

Knee Anterior Cruciate Ligament

Reconstruction Exercise after ACL reconstruction is vital to

recovery ACL controls knee motion and proprioceptive

feedback Recent reconstruction technology advances

have allowed for a speedier recovery from ACL tears

A graft of the central third of the patellar tendon or the hamstring is usually the graft source

Emphasis on reducing inflammation

Knee Movement and Exercise Guidelines

Post-operative contraindications include: Immediate active or resistive knee flexion until six weeks after

surgery Hamstring grafts preclude immediate post-operative

active or resistive knee flexion until approximately three to four weeks following surgery

For either graft discharge can be as early as four to six weeks

During rehab open (straight leg raises, leg curl, extension, abduction, etc.) and closed kinetic chain (lunges, squats, leg press, etc.) activities are recommended and important

Leg extension exercises should be performed with a range of motion of 90 degrees of knee flexion to 45 degrees of knee extension to decrease stress on ACL (adhere to this for a minimum of six months to a year)

Knee Open chain vs. Closed chain

Open chain Exercises that have the distal aspect of the

extremity terminating free in space. Ex: leg curl/extension, hip flexion/extension

Closed chain Exercises that occur with the distal part of

the extremity fixed to an object that is either stationary or moving.

Ex: leg press, squat, step-ups, barbell bench press

Knee Movement and Exercise Guidelines (Table 21.7, pg. 553)

Movement contraindications Open chain knee movements with <45 degrees knee flexion Active hamstring exercise (those with hamstring graft) for four

to six weeks Exercise contraidications

End range of leg extensions Exercise indications

¾ squat and leg press Step-up Leg curl Stiff-legged deadlift Elliptical trainer

Knee Total Knee Arthoplasty

Total knee replacement…generally due to year of stress and repetitive load on the knee (degeneration on the joint surfaces of the distal femur and proximal tibia)

Prosthetic components are inserted to cover worn areas at the ends of both the femur and tibia

Rehab is immediate with range of motion the focus

Emphasis on range of motion

Knee TKA

Movement and Exercise Guidelines Contraindications

Movements greater than 100 degrees of flexion are risky and can cause undue stress on knee

Exercises requiring kneeling (bent-over dumbbell row, lunges too deeply

Indications Exercises using less than 90 degrees knee flexion postures are

recommended in both open and closed kinetic chain exercises Cycling Swimming Endurance-based activities that minimize joint impact

loading Specific resistance exercises such as leg press, calf

raise and knee flexion with low resistance and high reps

Knee TKA (movement and exercise guidelines)

Movement contraindications (Table 21.7, pg. 553) Closed chain knee movements wth > 100 degrees knee flexion Kneeling

Exercise contraindications Full squat Full lunge

Exercise indications ¼ to ½ squat and leg press Partial lunge Leg extension and leg curl Stationary bicycle Aquatics, swimming

Hip

Trainers will encounter very few hip injuries or procedures

Hip is much more stable than shoulder or knee joint

Hip

Hip Arthroscopy Post-procedure

Focus on restoration of ROM, strength, and gait

Total time to return to activity is about 16 to 32 weeks but is determined by the extent of the surgical repair

Hip Hip arthroscopy

Movement and exercise guidelines (Table 21.8, pg. 557)

Movement contraindications Forceful hip flexion Hip abduction and rotation (early phase of

rehabilitation) Exercise contraindications

Ballistic or forced stretching Exercise indications

Aquatic walking

Hip Total Hip Arthroplasty (Hip Replacement)

Usually recommend if non-surgical procedures do not work

Replacement of hip provides about 15 years of pain free movement

Two types of prostheses Cemented

Affixing the femoral and acetabular components with bone cement

Uncemented Allow direct attachment of the prosthetic

components to the bone

Hip Cemented allows for immediate post-op

weight bearing Uncemented need six to twelve weeks

wait time before weight bearing after surgery

THA restrictions No hip flexion greater than 90 degrees No hip adduction past neutral No hip internal rotation

Hip Movement and Exercise Guidelines (Table

21.9, pg. 558) Trainer should first contact surgeon to see if there

are any other restrictions for exercise Weight bearing status:

Posterolateral approach: Immediate full weight bearing Anterolateral approach: Restricted weight bearing for ≥ 6 weeks Transtrochanteric approach: Restricted weight bearing for ≥ 6 weeks

ROM limitations Posterolateral approach: Flexion > 90 degree, abduction, medial rotation Anterolateral approach: Extension, adduction, lateral rotation Transtrochanteric approach: Extension, adduction, lateral rotation

Functional movement precautions Moving in and out of a chair, hip flexion (putting shoes on) Turning away from surgical hip Turning away from surgical hip

Arthritis

Two primary arthritis classifications Osteoarthritis

Degenerative joint disease Progressive destruction of joint’s articular

cartilage Rheumatoid Arthritis

Systemic inflammatory disease affecting not only the joint surface, but also connective tissue (capsules and ligaments)

Arthritis Osteoarthritis

Movement Exercise Guidelines (Table 21.10, pg. 559)

Movement contraindications High-impact activites

Exercise contraindications running Snow skiing Jogging

Exercise indications Bicycle Stair stepper Elliptical trainer Aquatics, swimming

Arthritis Rheumatoid Arthritis

Movement and Exercise Guidelines (21.11, pg. 560) Improve function during daily activities Improve general health Protect affected joints

Movement contraindications High-impact cardiovascular exercise Neck flexibility or strangthening in clients with history of neck instability Movements outside the safe zone

Exercise contraindications Running or jogging Upper trapezius stretch Manually resisted neck strengthening Behind-the-neck shoulder press

Exercise indications Moderate-intensity (60-80% maximal heart rate), aerobic endurance exercise Range of motion and flexibility exercises Isometric exercise (for the unstable joint) Water aerobics Stationary bicycling

Arthritis Common Modifications to Exercise

Common affected areas are cervical spine, shoulders and wrists

Cervical spine Avoid neck stretching or manual resistance in that

area Shoulders

Avoid impingement prone positions (upright row) Wrists

Increase diameter of bar, dumbbell or handle to offset weakened grip

May add a padding to a dumbbell bar