Overuse, or unaccustomed use, soft tissue injuries (STIs) occur when the recovery rate of bodily tissues is surpassed by the rate of micro-trauma caused through activity, exercise or just activities of daily living (ADLs). The tissues in question start to break down and eventually, pain or dysfunction occur. These injuries can occur in:
- Muscles: focal tissue thickening, fibrosis, adhesion
- Tendons: tendonitis, tendinosis, paratendonitis
- Bones: stress reactions (such as shin splints), stress fractures, osteitis (such as osteitis pubis)
- Cartilage: fibrillation, degeneration
- Bursa: bursitis
- Nerves: neural irritation or entrapment
- Ligaments: quite rare
- Skin: Blisters
As a physiotherapist specializing in gym and exercise related injuries, I get at least 3 new referrals per week from fitness professionals. Generally, the injury has not been caused by negligence by the trainer or instructor, but in many cases, it may have been avoidable. With the increase in popularity of boot camp style training (which I think is great) there has been a huge increase in soft tissue overuse injuries seen at my clinic.
Multiple problems arise for the personal trainer when a new boot camp client gets an injury:
- Loss of income while the client is off training.
- Having to fit them in later to make up the classes.
- Other participants wondering if they will get injured.
- The injured participant telling friends, colleagues and family about the “dangerous” program or bad mouthing the instructor.
One of our clients went to an outdoor training session conducted by another instructor. She reported back to me that there had been no pre-exercise screening, either written, physical, or verbal. She told the instructor that she was not very fit. During the session she tried, and was encouraged, to keep up with the others and soon broke down with a calf tear. She had four treatments at our center with a physiotherapist. She spent much of the time explaining how bad the instructor was and how she wouldn’t go back. Could this have happened in one of your classes?
Appropriate injury screening, prevention and management systems are an essential part of every PT business, particularly when conducting groups where there is less one-on-one exercise prescription. Use the following quiz to determine whether your processes are up to scratch.
- Do you have current PI and PL insurance
____No (if you tick this give up training now!)
- Do you have a written medical screening form which is completed by every client?
- Do you require written doctor's consent prior to starting exercise for clients with existing medical problems or injuries?
- Do you liaise with the clients physiotherapist (or other) prior to commencement of exercise if they have an injury?
- Do you provide new participants with written information about overuse injuries or injury prevention?
- Do you have systems in place for if a client is injured during a training session or reports an injury at the next session?
- Do you have an awareness of the intrinsic and extrinsic factors that can contribute to soft tissue injuries?
This should give you an understanding of where systems can be improved to manage risk more appropriately and better serve your clients.
Soft Tissue Injury Model
The contributors to Soft Tissue Injuries (STI) can be divided into four areas:
- Intrinsic factors
- Extrinsic factors
- Equipment errors
- Training errors/exercise volume
This is the area with the greatest amount of considerations in the analysis of STI’s. Some intrinsic factors are not open to influence.
- Genetic bony anomalies such as ante-verted femurs or spondylolithesis
- Diseases such as rheumatoid arthritis
- Previous injuries such as cartilage damage or scar tissue affecting muscle
Other intrinsic factors might be influenced or corrected, such as:
- Muscle imbalance such as tight hip flexors and weak gluteals
- Other specific muscle weakness
- Other specific muscle tightness
- Pronated feet
- Spinal stiffness
- Poor rehabilitation from previous injury
- Poor proprioception
Intrinsic factors are a huge contributor to STI’s and appropriate physical and written screening of clients is essential to identify areas you may be able to help with.
The main one of these tends to be the running surface. Running on bitumen or concrete paths will obviously generate more ground reaction force (or joint load) than grass. One of the other common mistakes I see is people running on the hard sand at the beach when there is a bit of a slope leading down to the water. Run 2 kilometers on a 5 degree angle and you are asking for trouble.
It is possible that running or exercising in very cold weather could contribute to injury especially before you are warmed up properly. Many people report their muscles feel tighter in cold weather and persons with arthritic joints also can feel stiffer
The biggest single factor that you can influence in terms of lower limb injuries is footwear. Daily in the clinic I see patients who have been running in shoes that are 18 months, 2 years or even 3 years old. Every pair of shoes has only a certain amount of steps after which they lose their shock absorption capacity. Once the shoe doesn’t absorb the shock, the leg does. And having a pair of shoes correctly fitted is also essential. I always refer my clients to a particular store where I know the staff undergo extensive training in foot mechanics, shoe design, lower limb injuries and footwear prescription. As a general rule, anyone who is complaining of lower limb STIs who is exercising in shoes that are older than 6 months should have new shoes correctly fitted.
Other sports can have unique equipment errors also. The most common is tennis where playing with wet balls in the rain, or having the racquet too highly strung can contribute to tennis elbow (lateral epicondylitis). Obviously not wearing a mouth guard or other protective equipment can also lead to injury.
Probably the biggest contributor to STIs is a sudden increase in training load, primarily running. The boot camp situation is the one I see the most where an untrained client goes from no exercise to 3 sessions of running per week for 6 weeks and wonders why they end up with an injury. Many of the clients think the pain must be normal as they haven’t exercised for a while or feel “soft” if they complain about it. Trainers need to educate clients early on in regard to what is normal or acceptable pain and that they need to be informed if a client is getting sore or is worried about an injury.
Our bodily tissues such as tendons, muscles and bones, adapt well with a structured and gradual increase in load. If the increase in load is faster than the adaptive ability of the tissues then they will start to break down resulting in tendonitis, stress fractures, myofascial (muscular) pain and others.
The following table displays the four main types of risk factors for overuse injuries. In the first case (number 1) the combined risk factor contribution will not result in injury or pain.
In Case 2, an intrinsic error, such as weak gluteals, pushes the injury risk over the critical line and injury will result.
In order for this person to improve, they must be brought under the critical line so that the affected tissues can heal. Obviously, the best course of action is to look at the intrinsic factor causing the problem, and strengthen the gluteals. This may take time, so we could also reduce the training load, which would bring the combined risk even lower and speed up the healing process (Case 3 above).
A friend of mine came to see me two years ago with severe lateral ankle pain. She had gone from running three times per week for 20 minutes to the same volume of running, plus three step classes at the gym per week and tennis twice per week. Her shoes were two years old and she had very pronated feet. By the time she saw me, she had rested for three days and her pain could not be reproduced in the clinic. I put her in some heat moldable orthotics and got her fitted with new trainers. She was able to return to this new volume of exercise (with no pain) immediately and with no further treatment required. The new shoes (equipment error) and orthotics (intrinsic error) bought her back under the critical line.
Types of Soft Tissue Injuries and What to Expect
When encountered with a client who has a new STI or overuse injury, it is vital to have an awareness about the likely recovery times, treatment required and return to activity timelines. Unfortunately the advice often given is “have a week off” with no thought to causative factors, treatment and corrective exercises.
Tendonitis literally means inflammation of a tendon. Recent research is now suggesting that tendon problems are actually more of a degenerative process than an inflammatory one so the term tendonitis may gradually be replaced by tendinosis (or tendonopathy, a more generic term). The most common sites of tendonitis are the Achilles tendon, the patella tendon, the common extensor tendon of the elbow (tennis elbow) and the supraspinatus tendon.
In general tendons are very poor healers as the blood supply is often poor. Some studies have suggested the average healing times for tennis elbow and Achilles tendonitis are around 12 months.
Therefore, it is vital that if one of your clients presents with suspected tendonitis you should refer them to a physiotherapist or sports physician for diagnosis and advice on treatment and management. Brukner and Khan (2002) describe three grades of tendinosis:
- Mild Tendinosis. Pain with activity only/pain that disappears with activity
- Moderate Tendinosis. Pain with sporting activity but not with activities of daily living
- Severe Tendinosis. Pain with activities of daily living
As a guide, those with mild tendonitis can continue with their current levels of activity whilst receiving treatment. Those with moderate symptoms with need treatment and activity modification. Those with severe tendonitis will need a period of rest, treatment and can expect a long slow recovery.
Fortunately, I only see about 2-3 new cases of stress fractures per year. Nearly every case is due to a sudden and significant increase in exercise load, often higher impact such as running and classes. There is often no rest days in the clients program for tissue recovery. The most common areas are the neck of the femur, the tibia and the distal fibula. If the stress fracture has progressed significantly there will be a period of non weight-bearing (crutches) followed by a gradual return to activity. On average a stress fracture will take 3 months to fully recover but cases can vary considerably.
The most common stress reaction we see is shin splints (medial tibial stress syndrome). The medial attachment of soleus pulls on the tibia and causes a tractional injury that develops into a stress reaction. This can turn into a stress fracture if left unchecked. The most common causes are tight calves and excessive pronation of the feet. A sudden or unaccustomed increase in activity is nearly always a causative factor. The pain is felt down the medial side of the tibia, usually around the middle to distal third of the tibia.
So how do we reduce risk?
I believe that all boot camp type programs should have three levels: Beginner, Intermediate and Advanced. Even if there are not enough participants for three separate groups, it is important to determine three levels for each exercise and advise each participant which level to choose.
Each participant should also be given a handout on what to expect from training, especially if they are coming from a low fitness base. They should be advised that it is not a “no pain,no gain” situation and what is a normal amount of DOMs versus what is abnormal pain. Procedures should be in place for suspending a client's boot camp or personal training program if they are injured and resuming once the injury is resolved.
They should be instructed to advise the instructor at the first sign of any new pain or niggle and not feel like they are being weak or annoying.
Boot camp instructors also need to seek out courses that improve their ability to recognize common injuries and should also seek to form a relationship with a local physiotherapist for cross-referral and injury advice.
- Brukner, P and Khan, K. Clinical Sports Medicine (2nd Ed) 2002. Mcgraw-Hill, Australia.