Clients w/ Orthopedic, Clients w/ Orthopedic,

Injury and Rehabilitation Injury and Rehabilitation

ConcernsConcerns

Chapter 21Chapter 21

TerminologyTerminology►► MacrotraumaMacrotrauma –– A specific, sudden episode of overload injury to a given tissueA specific, sudden episode of overload injury to a given tissue, ,

resulting in disrupted tissue integrity (Acute)resulting in disrupted tissue integrity (Acute)

►► MicrotraumaMicrotrauma –– Overuse injury that results from repeated, abnormal stress applOveruse injury that results from repeated, abnormal stress applied ied to a tissue by continuous training or training with too little rto a tissue by continuous training or training with too little recovery time (Chronic)ecovery time (Chronic)

►► EdemaEdema –– Escape of fluid into the surrounding tissuesEscape of fluid into the surrounding tissues–– inhibiting contractile tissue inhibiting contractile tissue function and significantly limiting the injured clientfunction and significantly limiting the injured client’’s activity level s activity level

►► Collagen fibersCollagen fibers –– The structural component of new tissue that are strongest when The structural component of new tissue that are strongest when they are lie longitudinally to the primary line of stress.they are lie longitudinally to the primary line of stress.

►► IndicationIndication –– An activity that will benefit the injured clientAn activity that will benefit the injured client

►► ContraindicationContraindication –– An activity or practice that is inadvisable or prohibited becauAn activity or practice that is inadvisable or prohibited because se of the given injuryof the given injury

►► PrecautionPrecaution –– An activity that may be performed under supervision of a qualifAn activity that may be performed under supervision of a qualified ied personal trainer and according to client limitations and symptompersonal trainer and according to client limitations and symptom reproductionreproduction

►► Annulus fibrosusAnnulus fibrosus –– Tough outer layer of intervertebral diskTough outer layer of intervertebral disk

►► Nucleus pulposusNucleus pulposus –– Gelatinous inner layer of intervertebral diskGelatinous inner layer of intervertebral disk

►► SpondylolysisSpondylolysis –– a defect or fracture of the arched area of the vertebra that a defect or fracture of the arched area of the vertebra that connects the superior and inferior facet jointsconnects the superior and inferior facet joints

►► SpondylolisthesisSpondylolisthesis –– the possible progression of spondylolysis, a forward slippage othe possible progression of spondylolysis, a forward slippage of f one vertebral body on another.one vertebral body on another.

►► DebridementDebridement –– involves scraping away at the edge of the tear until a clean, involves scraping away at the edge of the tear until a clean, bleeding surface of the tendon is achieved. Allows for greater bleeding surface of the tendon is achieved. Allows for greater healing.healing.

►► DecompressionDecompression –– Involves scraping or shaving away the bone on the anterior and Involves scraping or shaving away the bone on the anterior and inferior acromion to decrease stress or impingement of rotator cinferior acromion to decrease stress or impingement of rotator cuff tendonsuff tendons

Tissue Healing Following InjuryTissue Healing Following Injury

►► Inflammation PhaseInflammation Phase�� BodyBody’’s initial reaction to injury s initial reaction to injury

�� Necessary in order for normal healing to occurNecessary in order for normal healing to occur

�� Goal: Prepare for new tissue formation (production of new blood Goal: Prepare for new tissue formation (production of new blood vessels & collagen)vessels & collagen)►► R.I.C.E. (Rest, Ice, Compression, Elevation)R.I.C.E. (Rest, Ice, Compression, Elevation)

�� Exercise to injured area not recommended during this phase Exercise to injured area not recommended during this phase

►► Repair PhaseRepair Phase�� Allows for the replacement/regeneration of tissues Allows for the replacement/regeneration of tissues

�� Goals: Prevent excessive muscle atrophy and joint degeneration, Goals: Prevent excessive muscle atrophy and joint degeneration, promote collagen synthesis, avoid disruption of the newly formedpromote collagen synthesis, avoid disruption of the newly formedcollagen fibers collagen fibers

�� Balance w/ intro of lowBalance w/ intro of low--load stresses (promote collagen production load stresses (promote collagen production & maintain joint motion)& maintain joint motion)

�� Follow the PhysicianFollow the Physician’’s Orders w/ exercises Orders w/ exercise

Tissue Healing Following Injury ContTissue Healing Following Injury Cont’’

►► Remodeling PhaseRemodeling Phase

�� Weakened tissue produced during repair is strengthenedWeakened tissue produced during repair is strengthened

►►Collagen fibers and scar tissues hypertrophy and align more Collagen fibers and scar tissues hypertrophy and align more

along lines of stress along lines of stress

�� Goal: Optimize tissue function by continuing exercises performedGoal: Optimize tissue function by continuing exercises performed

during repair and by adding more advanced activityduring repair and by adding more advanced activity--specific specific

exercises and progressive stresses to injured tissuesexercises and progressive stresses to injured tissues

Goals During Tissue HealingGoals During Tissue Healing

PhasePhase Duration Duration EventsEvents

InflammationInflammation Minimum 2 Minimum 2 -- 3 days3 days Pain, swelling, and rednessPain, swelling, and redness

Decreased collagen synthesisDecreased collagen synthesis

Increased number of inflammatory cellsIncreased number of inflammatory cells

RepairRepair Begins w/in 3 Begins w/in 3 -- 5 days 5 days

and may last up to and may last up to

2 months2 months

Collagen fiber productionCollagen fiber production

Decreased collagen fiber organization Decreased collagen fiber organization

Decreased number of inflammatory cellsDecreased number of inflammatory cells

RemodelingRemodeling 2 2 -- 4 months (or 4 months (or

longer) longer) Proper collagen fiber alignmentProper collagen fiber alignment

Increased tissue strengthIncreased tissue strength

Low BackLow Back

►► Lumbar Disc InjuryLumbar Disc Injury�� Anatomical LimitationsAnatomical Limitations

►► Lumbar region: Annulus fibrosus reinforced anteriorly by strong Lumbar region: Annulus fibrosus reinforced anteriorly by strong anterior longitudinal ligament; posterior support limited becausanterior longitudinal ligament; posterior support limited because the e the posterior longitudinal ligament narrows posterior longitudinal ligament narrows

�� Disc herniationsDisc herniations►► Part of the nucleus pulposus makes its way through the outer Part of the nucleus pulposus makes its way through the outer annulus fibrosus, resulting in inflammation that irritates the sannulus fibrosus, resulting in inflammation that irritates the spinal pinal rootsroots

�� Movement GuidelinesMovement Guidelines►► Generally avoid lumbar flexion in favor of extension Generally avoid lumbar flexion in favor of extension

►► Resistance Contraindications may include full sitResistance Contraindications may include full sit--upsups

►► Resistance Precautions may include squats, all rowing movements,Resistance Precautions may include squats, all rowing movements,and the deadliftand the deadlift

►► Cardio Precautions may include those that encourage flexion (bikCardio Precautions may include those that encourage flexion (bike e or flexion based aerobics)or flexion based aerobics)

►► Flexibility important for those w/ disc injuries; ContraindicatiFlexibility important for those w/ disc injuries; Contraindications are ons are those that involve lumbar flexion (Standing toe touch); Precautithose that involve lumbar flexion (Standing toe touch); Precautions ons may include gluteal, hip adductor and upper back stretchesmay include gluteal, hip adductor and upper back stretches

Anatomical LimitationsAnatomical Limitations

Anatomy Lumbar SpineAnatomy Lumbar Spine

Lumbar Disc HerniationLumbar Disc Herniation

Low Back ContLow Back Cont’’

►► Muscle StrainsMuscle Strains�� As discussed earlier they are tears to the muscle fibersAs discussed earlier they are tears to the muscle fibers

�� Movement GuidelinesMovement Guidelines

►► Once determined by physician or physical therapist which muscle Once determined by physician or physical therapist which muscle has has been strained, exercises and movements for that muscle should bebeen strained, exercises and movements for that muscle should beavoided during early phases of healingavoided during early phases of healing

►► Spondylolysis and SpondylolisthesisSpondylolysis and Spondylolisthesis�� Commonly occurs following lumbar extension injuries or in personCommonly occurs following lumbar extension injuries or in persons s requiring lumber extension (divers, gymnasts, etc.)requiring lumber extension (divers, gymnasts, etc.)

�� Movement GuidelinesMovement Guidelines

►► Clients should focus on strengthening the muscles surrounding thClients should focus on strengthening the muscles surrounding the e spine and avoid exercises involving lumber extensionspine and avoid exercises involving lumber extension

►► Cardiovascular activities should be modified to adapt to clientsCardiovascular activities should be modified to adapt to clients needs / needs / levels tolerance levels tolerance

Spondylolysis and SpondylolisthesisSpondylolysis and Spondylolisthesis

Low Back Pain Movement and Low Back Pain Movement and

Exercise GuidelinesExercise GuidelinesDiagnosisDiagnosis Movement Movement

contraindicationscontraindicationsExercise Exercise

contraindications contraindications Exercise indications Exercise indications

Disc injuryDisc injury --Lumbar flexionLumbar flexion

--Lumbar rotationLumbar rotation

--SitSit--upup

--Knee to chest stretchKnee to chest stretch

--Spinal twistSpinal twist

--Passive lumbar extension Passive lumbar extension

stretchesstretches

--Isometric ab and Isometric ab and

extensor strengthening, extensor strengthening,

progressing to lumbar progressing to lumbar

stabilization programstabilization program

Muscle strainMuscle strain --Passive lumbar flexion Passive lumbar flexion

(during inflammatory (during inflammatory

phase)phase)

--Active lumbar extension Active lumbar extension

(during inflammatory (during inflammatory

phase)phase)

--Knee to chest stretchKnee to chest stretch --None during None during

inflammatory phase, inflammatory phase,

progressing to gentle progressing to gentle

flexion stretching, flexion stretching,

followed by extension followed by extension

strengthening strengthening

Spondylolysis Spondylolysis

and and

SpondylolisthesisSpondylolisthesis

--Lumbar extensionLumbar extension --SquatSquat

--Shoulder press Shoulder press

--Push pressPush press

--Knee to chest stretchKnee to chest stretch

--Abdominal crunchAbdominal crunch

ShoulderShoulder

►► Impingement SyndromeImpingement Syndrome�� ““PinchingPinching”” of the supraspinatus, long head of the biceps tendon, or of the supraspinatus, long head of the biceps tendon, or subacromial bursa under the acromial archsubacromial bursa under the acromial arch

�� Causes: Causes: ►► Hooked Acromion, muscle imbalances, poor posture, poor scapular Hooked Acromion, muscle imbalances, poor posture, poor scapular control, improper exercise technique/excessive ROM, and overuse control, improper exercise technique/excessive ROM, and overuse of of shoulder (typically overhead) shoulder (typically overhead)

�� Movement GuidelinesMovement Guidelines►► Implement Rotator Cuff & Scapular exercises (rhomboids, middle &Implement Rotator Cuff & Scapular exercises (rhomboids, middle &lower trapezius) to promote muscle balance/controllower trapezius) to promote muscle balance/control

►► Overhead presses exercises and all bench presses used cautiouslyOverhead presses exercises and all bench presses used cautiously�� Decline might be most appropriate for reintroduction Decline might be most appropriate for reintroduction

►► Avoid exercises that raise the elbow too high Avoid exercises that raise the elbow too high

►► Lat pulldown behind the head is contraindicatedLat pulldown behind the head is contraindicated

►► Cardio exercises that place the arm overhead should be used withCardio exercises that place the arm overhead should be used withcaution caution

Shoulder ContShoulder Cont’’

►► Anterior InstabilityAnterior Instability

�� Where the head of the humerus moves too far Where the head of the humerus moves too far

forward, resulting in possible injury or dislocation.forward, resulting in possible injury or dislocation.

�� Shoulder dislocation is likely to reoccur after initial Shoulder dislocation is likely to reoccur after initial

dislocation (especially in the young)dislocation (especially in the young)

�� Movement GuidelinesMovement Guidelines

►►Rotator Cuff & Scapular Strengthening Rotator Cuff & Scapular Strengthening

►►Contraindications in table 21.3 Contraindications in table 21.3 mustmust be followed closelybe followed closely

►►Shoulder exercises should stay within the Shoulder exercises should stay within the ““safe zonesafe zone””

►►Cardio and Flexibility exercises should be limited to those Cardio and Flexibility exercises should be limited to those

that remain within the that remain within the ““safe zonesafe zone””

Shoulder ContShoulder Cont’’

►► Rotator Cuff Debridement and Subacromial Rotator Cuff Debridement and Subacromial Decompression Decompression �� Movement GuidelinesMovement Guidelines

►► FOLLOW THE PHYSICAL THERAPISTFOLLOW THE PHYSICAL THERAPIST’’S GUIDELINESS GUIDELINES

►► Continue rotator cuff & scapular strengthening exercisesContinue rotator cuff & scapular strengthening exercises

►► Contraindications after these procedures are low rep high intensContraindications after these procedures are low rep high intensity ity exercises and exercises outside the exercises and exercises outside the ““safe zonesafe zone””

►► After rehab and recovery is complete, most activities are indicaAfter rehab and recovery is complete, most activities are indicated ted but caution must be used but caution must be used

►► Rotator Cuff RepairRotator Cuff Repair�� Most often carried out when there is a tear through the full Most often carried out when there is a tear through the full thickness of the musclethickness of the muscle

�� Movement GuidelinesMovement Guidelines

►► Amount of time immobilized determined by physicianAmount of time immobilized determined by physician

►► Rehab includes rotator cuff & scapular strengthening Rehab includes rotator cuff & scapular strengthening

►► Contraindications: Listed on table 21.3 pg. 545Contraindications: Listed on table 21.3 pg. 545

KneeKnee

►► Anterior Knee PainAnterior Knee Pain�� Common description by clients that includes many Common description by clients that includes many possible diagnoses caused by poor mechanics, overuse possible diagnoses caused by poor mechanics, overuse or muscle imbalancesor muscle imbalances

�� Individual approach must be taken with each diagnoses Individual approach must be taken with each diagnoses

�� Rehab would focus on reducing inflammation and Rehab would focus on reducing inflammation and optimizing tissue functionoptimizing tissue function

�� Movement Guidelines Movement Guidelines ►►Exercises requiring greater than 90 Degrees of knee flexion Exercises requiring greater than 90 Degrees of knee flexion must be used with caution must be used with caution

►►90 degrees contraindicated in high impact aerobics; generally 90 degrees contraindicated in high impact aerobics; generally recommend cycling or water based aerobic activitiesrecommend cycling or water based aerobic activities

Knee ContKnee Cont’’

►►Anatomy of the KneeAnatomy of the Knee

Knee ContKnee Cont’’

►► Anterior Cruciate Ligament (ACL) ReconstructionAnterior Cruciate Ligament (ACL) Reconstruction�� Graft taken to reconstruct the ACL (patellar, Graft taken to reconstruct the ACL (patellar, semitendinosus, or gracilis)semitendinosus, or gracilis)

�� Movement GuidelinesMovement Guidelines►►After discharged from rehab should have full ROM and good After discharged from rehab should have full ROM and good quad strength/functionquad strength/function

►►Post rehab exercises should combine Open and Closed chain Post rehab exercises should combine Open and Closed chain exercisesexercises

►►Leg extension should be used with caution (Leg extension should be used with caution (last 30 degrees last 30 degrees = = most stress on ACL) for first most stress on ACL) for first 6 months to 1 year6 months to 1 year

►►Contraindications: Full ROM extension and Closed Chain Contraindications: Full ROM extension and Closed Chain exercises w/ more than 90 degree knee flexionexercises w/ more than 90 degree knee flexion

►►Take into account where graft was taken fromTake into account where graft was taken from

Knee ContKnee Cont’’

►►Total Knee ArthroplastyTotal Knee Arthroplasty

�� Total knee replacement where prosthetics are Total knee replacement where prosthetics are

inserted to cover worn areas of the femur and inserted to cover worn areas of the femur and

tibiatibia

►►Movement GuidelinesMovement Guidelines

�� Table 21.5 pg. 550Table 21.5 pg. 550

HipHip

►►Total Hip ArthroplastyTotal Hip Arthroplasty

�� Total hip replacement where prosthetics are Total hip replacement where prosthetics are

inserted to cover worn areas of the femur inserted to cover worn areas of the femur

�� Movement Guidelines Movement Guidelines

►►indicated on table 21.5 pg. 550indicated on table 21.5 pg. 550

ArthritisArthritis

►► OsteoarthritisOsteoarthritis�� The progressive destruction of a jointThe progressive destruction of a joint’’s articular cartilage.s articular cartilage.

�� Often manifests itself as spurs or osteophytes that interfere w/Often manifests itself as spurs or osteophytes that interfere w/normal joint function and cause pain and limited ROMnormal joint function and cause pain and limited ROM

�� Leads to bone on bone contact that causes inflammationLeads to bone on bone contact that causes inflammation

�� Movement GuidelinesMovement Guidelines►► LowLow--resistance, high repetition, minimize loading of articular surfaresistance, high repetition, minimize loading of articular surfaces ces (water based, bikes, etc)(water based, bikes, etc)

►► Typically open chain exercises better because of less compressivTypically open chain exercises better because of less compressive e forcesforces

►► Guidelines table 21.7 pg. 552Guidelines table 21.7 pg. 552

►► Rheumatoid ArthritisRheumatoid Arthritis�� A systemic inflammatory disease affecting not only joint surfaceA systemic inflammatory disease affecting not only joint surface, , but also connective tissue (joint capsules and ligaments)but also connective tissue (joint capsules and ligaments)

�� Movement GuidelinesMovement Guidelines►► Neck specific exercises contraindicatedNeck specific exercises contraindicated

►► Guidelines table 21.8 pg. 553Guidelines table 21.8 pg. 553