Overuse, or unaccustomed use, soft tissue injuries (STI’s) 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

(ADL’s). The tissues in question start to break down and eventually pain

or dysfunction occur. These injuries can occur in:

a) Muscles: focal tissue thickening, fibrosis, adhesions

b) Tendons: tendonitis, tendinosis, paratendonitis

c) Bones: stress reactions (such as shin splints), stress fractures, osteitis (such as osteitis pubis)

d) Cartilage: fibrillation, degeneration

e) Bursa: bursitis

f) Nerves: neural irritation or entrapment

g) Ligaments: quite rare

h) Skin: Blisters

As a physio specialising in gym and exercise related injuries I get at least 3 new referrals per week from PT’s.

Generally, the injury has not been caused by negligence by the trainer but in many cases it may have been

avoidable. With the increase in popularity of Bootcamp 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 bootcamp client gets an injury:

1) Loss of income while the client is off training

2) Having to fit them in later to make up the classes

3) Other participants wondering if they will get injured

4) The injured participant telling friends, colleagues and family about the “dangerous” program or

bad mouthing the trainer.

BOOT CAMP BLUNDERS:

INJURY PREVENTION AND MANAGEMENT FOR PROFESSIONAL PERSONAL TRAINERSADAM FLOYD B.SC (PHYSIO) B.PE (HONS PHYSIOTHERAPIST AND EXERCISE PHYSIOLOGIST)

One of our PT clients went to try an outdoor training session with a friend conducted by another PT. She reported

back to me that there had been no pre-exercise screening, either written, physical or even verbal. She told the

trainer she was not very fit. During the session she tried and was encouraged to keep up with the others and

broke down with a calf tear. She then had 4 treatments at our centre with one of the physios. She spent much

time telling us how bad the other trainer was and how she wouldn’t go back. Could this, or has this, scenario have

happened to you?

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.

Question 1: Do you have current PI and PL insurance

Yes No (if you tick this give up training now!)

Question 2: Do you have a written medical screening form which is completed by every client?

Yes No

Question 3: Do you require written Doctors consent prior to commencement of exercise for

clients with existing medical problems or injuries?

Yes Mostly No

Question 4: Do you liaise with the clients Physio (or other) prior to commencement of exercise

if they have an injury?

Yes Mostly Sometimes No

Question 5: Do you provide new participants with written information about

overuse injuries or injury prevention?

Yes No

Question 6: Do you have systems in place for if a client is injured during a training session or

reports an injury at the next session?

Yes No

Question 7: Do you have an awareness of the intrinsic and extrinsic factors that can contribute to

soft tissue injuries?

Yes No

Hopefully this has given you an understanding of where you can improve your systems to manage risk more

appropriately and better serve your clients.

The remainder of this paper will guide the professional personal trainer through a model of soft tissue overuse

injuries and appropriate prevention and management strategies.

I SOFT TISSUE INJURY MODEL

We can divide the contributors to STI’s into four areas:

1) Intrinsic factors

2) Extrinsic factors

3) Training errors/exercise volume

4) Equipment errors

Let’s examine each of these in turn.

Intrinsic factors

This is possibly the area with the greatest amount of considerations in the analysis of STI’s. Some intrinsic factors

we are not able to influence or change.

Examples would include

a) Sex

b) Age

c) Genetic bony anomalies such as ante-verted femurs or spondylolithesis

d) Diseases such as rheumatoid arthritis

e) Previous injuries such as cartilage damage or scar tissue affecting muscle

Other intrinsic factors we may be able to improve on or correct.

a) Muscle imbalance such as tight hip flexors and weak gluteals

b) Other specific muscle weakness

c) Other specific muscle tightness

d) Overweight

e) Unfit

f) Pronated feet

g) Spinal stiffness

h) Poor rehabilitation from previous injury

i) 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.

Extrinsic/Environmental Factors

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 km’s 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.

Equipment Errors

The biggest single factor that you can influence in terms of lower limb injuries is footwear. Time and time again 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 STI’s

who is exercising in shoes that are older than 6 months should have new shoes correctly fitted.

I always ask clients to bring their shoes in for me to examine. In many cases the laces are still tied up even though

the shoes are off indicating that the person is removing the shoe by stepping on the heel and forcing them off the

lazy way. This stretches the heel cup of the shoe and will result in a less snug fit for the rear-foot. The rear-foot

then moves around more in the shoe and results in decreased stability. Always get clients to untie laces before

removing their shoes (without sounding like their mother!)

I’m also not a fan of leather “walking” shoes in older clients. For some reason they seem to be talked into buying

(often expensive) walkers rather than getting into good quality trainers/sneakers. These shoes do not seem to

have the same degree of sole construction in terms of density and therefore shock absorption ability.

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.

Training Error

Probably the biggest contributor to STI’s is a sudden or unaccustomed 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 shin splints, Achilles tendonitis, patella-femoral

pain or similar. 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, myofacial (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.

1 2 3

Critical line for injuries

Intrinsic Faults

Training volume/errors

Equipment errors

Environmental errors

In Case 2, an intrinsic error, such as weak gluteals, pushes the injury risk over the critical line and injury will

result.

If we want to get this person better we need to bring them back down 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)

Case Study

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 we could not reproduce her pain in the clinic. I put her in some heat mouldable

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.

I 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/Tendinosis

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: Pain with activity only/pain that disappears with activity

Moderate: Pain with sporting activity but not with activities of daily living

Severe: 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.

Stress reactions/fractures

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.

Myo-fascial pain

Myo-fascial pain refers to pain coming from muscles and/or fascia. It is very common for older clients to complain

of progressively tight muscles or pain when commencing new exercise modalities such as running, sport or higher

impact classes. A myo-fascial trigger point is a “knot” or band within a muscle that tightens up, won’t let go with

stretching and becomes a pain generating source. Travel and Simons mapped out the common referral sources

for myo-fascial trigger points by injecting normal muscles with saline (an irritant) and asking for a description of

where the subject felt pain. For example, it is common for a trigger point in the upper trapezius to refer to the side

of the temple (head) and for the piriformis to refer to the posterior thigh.

Fortunately most trigger points and tight bands respond really well to treatment consisting of heat, soft tissue

releases/massage and stretching after. Many physios, such as myself, use acupuncture to release the trigger point

or tight band and this works brilliantly in most cases. Often the client is back to full activity within 1-2 weeks

(although I had a stubborn calf with multiple tight bands that stopped me from running for 6 weeks – I kept

trying to go back too early!).

If you suspect a client is complaining of myo-fascial pain, see if you can palpate a tight tender band or knot of

muscle and if so refer to a physio asap. You can also advise on heat and appropriate stretches. I, and a number

of my patients, find that “Skins®” help with muscle recovery from exercise and feel ‘more warmed up” during

exercise but this is anecdotal.

The most common sites of myo-fascial pain are the calves, hamstrings, gluteals (piriformis in particular), the

rhomboids and the upper trapezius. Posture and ergonomics plays a huge role, particularly in the upper body

trigger points. Improving a clients sitting posture can significantly reduce myo-fascial pain in the upper quadrant.

I SO HOW DO WE REDUCE RISK?

I believe that all boot-camp type programs should have three levels: Beginners, Intermediate and Advanced. Even

if there are not enough participants for three separate groups determine three levels for each exercise and advice

each client which level to choose.

Each client should also be given a hand-out 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 DOM’s versus what is abnormal pain. Procedures should be in place for suspending a clients bootcamp or PT

program if they are injured and resuming once the injury is resolved.

They should be instructed to advise the trainer at the first sign of any new pain or niggle and not feel like they are

being weak or annoying.

Trainers also need to seek out courses that improve their ability to recognise common injuries and should also seek

to form a relationship with a local Physiotherapist for crossreferral and injury advice.

I am currently in the process of compiling a bank of useful information and tools for Personal Trainers and

Exercise Physiologists to use with their clients. Information will be distributed via the adamfloyd.com.au

newsletter as it becomes available. Any comments or further topics you would like to hear about please email

Adam at adam@adamfloyd.com.au.

References

Brukner, P and Khan, K. Clinical Sports Medicine (2nd Ed) 2002. Mcgraw-Hill, Australia

This article has been written and provided by Adam Floyd,

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