8/21/13

Common Soft Tissue Conditions

19 August 2013 HS3 407 1300hrs Seminar

Content
Muscular pathology Hamstring muscle strain Pectoralis minor tightness Tendoachilles rupture Ligament pathology ACL rupture Ankle lateral ligament sprain Dorsal dislocation of PIPJ of hand Pathology from traumatic contact Anterior lower leg contusion Olecranon bursitis

"

Hamstring Muscle Strain

Hamstring strain injuries:

Hamstring Muscle Strain

Muscular pathology Group 2b

Characterised by acute pain in the posterior thigh with

disruption of the hamstring muscle fibers. function.

(Opar, & Williams, 2012)

Grade 1 Minor microscopic tearing and some loss of

Grade 2 Partial tearing with more noticeable pain and

swelling and definite loss in strength.

Grade 3 Full rupture of the muscle with complete loss of

function

(Kishan, & Sekhar , 2008)

"

[Image] Retrieved from: http://runnersforlife.com/profiles/blogs/rehabilitating-hamstring-injury

Aetiology

Risk Factors
Modifiable Risk Factors:

Explosive sports (Ropiak & Bosco, 2012) E.g. Running, kicking, jumping, and hurdling High level of muscle strain High force eccentric contractions Slow-speed stretching (Asking & Tengvar , 2007) E.g. dancing, water skiing and gymnastics Extensive hip flexion and knee extension Hamstring muscles stretched beyond their
[Image] Retrieved from:http://www.coreperformance.com/knowledge/ injury-pain/hamstring-strain.html

Shortened optimum muscle length Overall lack of flexibility Muscle fatigue

Retrieved from: http://fxrxinc.com/blog/sports-medicine/the-basics-ofhamstring-injuries-from-fxrx/

Increased neural tension Strength imbalances Poor lumbar spine posture Non-modifiable Risk Factors: Muscle compositions Age Race Previous injuries
(Verrall & Slavotinek, 2001)

limits

Retrieved from:http://perfectformphysio.com.au/article/ dance-injuries/preventing-hamstring-tears/

8/21/13

Lumbar Spine Related Hamstring Injury

Expected Clinical course

Initial Injury Grade I minimal swelling, some tenderness or discomfort during

Impingement of L5 nerve root (Orchard & Farhart, 2004) L5 nerve can be easily compressed by

movement function function

lumbosacral ligament
Correlation between entrapment of L5 nerve

Grade II mild to moderate swelling, pain and tenderness, some loss of Grade III severe pain and immediate swelling, complete loss of
(Gokaraju, Garikipati & Ashwood, 2008)

and hamstring injuries

Referred pain from lumbar spine (Hunter, 2007)
Hamstrings innervated by sciatic nerve (L5-S2)
(Drake, Vogl & Mitchell, 2010)

Recovery time frame Grade I 2 -5 days for tenderness and discomfort to subside Grade 2 Symptoms may last up to a few weeks or a month.
[Image] Retrieved from: http://cspringsphysio.com.au/ conditions/back-pain.html

Pain referral from lumbar spine can mimic

hamstring strain MRI scans and specific examination procedures can help in differential diagnosis

Some mild bruising and continued tenderness during this time.

(National Institues of Health, 2012)

Expected Clinical Course

Grade III In cases of avulsion and complete muscle tears,

Management Strategies
Non-operative
(Ali & Leland 2011; Kishan,2008)

surgery may be required.

there may be extensive ecchymosis, swelling, and dramatic

RICE (Rest, Ice, Compression, Elevation Therapeutic stretches Massage Exercise NSAIDS (Non-steroidal anti-inflammatory drugs) Operative
(Ali & Leland, 2011)

bruising in the thigh, as this injury causes a persistent and remarkable intramuscular hematoma and edema. (Abebe,
Moorman & Garrett, 2012)

Post surgery Weight Bearing

02 weeks: Toe-touch weight bearing (10% of weight) 24 weeks: 25% weight bearing 46 weeks: 50% weight bearing 6+ weeks: weight bearing as tolerated
(Ali & Leland, 2012)

Surgery Usually reserved for complete ruptures of hamstring from ischial

[Image] Retrieved from:http://www.eorthopod.com/ content/hamstring-injuries

tuberosity

Aetiology
Poor posture over prolonged periods Muscle imbalance (Cortiva, 2006) Dysfunctional breathing Repetitive overuse or stress injury to muscle Trauma (Lewis, & Valentine, 2007)
[Image] Retrieved from: http://thedailyjog.com/ wp-content/uploads/2012/09/bad-computerposture-dude5.jpeg

Pectoralis Minor Tightness

Muscular pathology Group 2d

"

8/21/13

Risk factors
Intrinsic risk factors Age Gender More common in women Genetics Anatomical abnormalities Previous injuries (Lewis, & Valentine, 2007) Extrinsic risk factors Desk-based occupations Athletes involved in sports with an overhead action e.g. swimmers, baseball pitchers and rowers (Rondeau, Padua, Thigpen & Harrington, 2009)
[Image] Retrieved from: http://www.drdobbin.co.uk/triathlon-swim-sessions-forautumn-2011

Pathophysiological Processes

Neuroplasticity Poor posture over prolonged periods Muscle imbalance Weak antagonist muscles Altered reciprocal inhibition (Lewis, & Valentine, 2007) Dysfunctional breathing Quiet inspiration using chest/neck muscles
[Image] Retrieved from: rothbartsfoot.es/PectoralisMinor_Syndrome.html

Injury to pectoralis minor e.g. Scar tissue (CliftonSmith, & Rowley, 2011)

Expected Clinical Course: Signs and symptoms

Pain in the shoulder Tightness creates anterior tilt and forward pull of scapula protraction

Expected Clinical Course: Recovery

Following successful management and treatment
Manual therapy (stretching)

Following unsuccessful management and treatment

Possible outcomes

and depression (Lewis, & Valentine, 2007)

Affects trunk control Limitation of full scapular motion Prevents optimal scapular kinematics Specifically in upward rotation, retraction and posterior tilting
(Rondeau, Padua, Thigpen & Harrington, 2009)

Decreased pain Increased pectoralis minor length (Williams, Laudner & McLoda, 2013)

Shoulder impingement Scapular winging Permanent forward head posture Further decline of antagonist muscles Decline in pectoralis minor length Possible development of tightness in neck muscles
i.e. sternocleidomastoid
(Lewis, & Valentine, 2007)

Strengthening muscles of the back

Regain functional use of antagonist muscles Optimized posture Reduced risk for other muscular and joint complications in back region (Williams, Laudner & McLoda, 2013)

Management
Manual therapy Passive gross stretching of

Associated Problem: Thoracic Outlet Syndrome

Related to superior opening of thoracic cavity Group of disorders where blood vessels/nerves in thoracic

pectoralis minor muscle by physical therapist

Biofeedback techniques

outlet are compressed (Nicholas, 2009)

Aetiology Drooping shoulders/forward head position Pectoralis minor tightness

Signs and symptoms Pain in shoulders and neck Numbness in fingers Pain/weakness/numbness/cyanosis/swelling in
[Image] Retrieved from: http://www.laserhealthsolutions.com/ newsletters/issue42-01.png

(home or at work)
Use of mirror to correct posture Resistance exercises for

antagonist muscles
i.e. rhomboids,
Williams, Laudner & McLoda, 2013

infraspinatus, teres minor

(Cortiva, 2006)

upper extremity (Mayo Clinic, 2013)

8/21/13

Aetiology
Sudden forceful plantarflexion or push-off outside normal ROM (Nandra,

Tendoachilles Rupture
Muscular pathology Group 2a

Matharu & Porter, 2011)

Spontaneous rupture in presence of co-morbidity or degeneration of

tendon
Pushing off weight-bearing foot with knee extended Unexpected & violent planterflexion & dorsiflexion

of ankle (Hess, 2010)

"
[Image] Retrieved from http://www.drthefootwithoutthedoc.com/wpcontent/uploads/2012/06/achillerupture.jpg

Risk Factors
Intrinsic factors Poor biomechanics (Nandra, Matharu & Porter, 2011) Age (30-50 years old) Gender (male: female; 10:1) (Brukner & Khan, 2012) Pre-existing conditions (inflammatory & autoimmune diseases

Expected Clinical Course

Audible pop heard, sensation of being kicked in heel (Brukner & Khan, 2012) Acute: Possible minor swelling, tenderness & pain upon passive

etc.) (Almekinders & Maffulli, 2007)

dorsiflexion
2-6cm gap palpable above calcaneal attachment Chronic (4 weeks after injury): Difficulty in activities involving plantarflexion e.g. walking up

Extrinsic factors Recreational athletes (weekend warriors) Use of corticosteroids & fluoroquinolone antibiotics (Hess, 2010) High impact sports i.e. badminton, football, gymnastics, tennis
(Nandra, Matharu & Porter, 2011)

stairs, toe-off in walking

Gap less likely to be palpable due to formation of scar tissue &

Extreme changes in training, activity level Inappropriate footwear & training techniques (Nandra, Matharu & Porter,
2011)

thickening of tendon sheath (Nandra, Matharu & Porter, 2011)

Differential Diagnosis

Differential Diagnosis

Achilles tendinopathy Inflammation & scar tissue formed as a result of micro tears in

tendon
Cause: overuse Slow onset, with morning pain & stiffness Pain worsens during exercise but daily living activities minimally

affected (Paavola, Kannus, Jrvinen, Khan, Jzsa & Jrvinen, 2002)

(Nandra, Matharu & Porter, 2011)

8/21/13

Treatment
Operative Tendons dissected and re-joined via sutures Static splinting in Paris cast in equinus position (20 plantarflexion) 4-6 weeks, gradually moving into plantigrade
Conservative

ACL Ligament Rupture

Ligament pathology Group 2c

4 weeks in Paris cast in equinus position Pneumatic walker with heel lift (only when standing & walking) for further 4 weeks Degree of heel lift changed to increase amount of plantarflexion

Both followed by strengthening & ROM exercises

(Almekinders & Maffulli, 2007)

"

Aetiology

Risk Factors

[Image} Retrieved from: http:// www.podolsky.ca/gary/Skiinjuries.htm

[Image] Retrieved from: http://healthpages.org/wpcontent/uploads/2010/06/acl-tear.jpg

(Papoutsidakis, 2011) Cailliet 1991; Harvard health publications 2010; Micheo et al., 2010; Brukner & Kahn 2012)

Expected Clinical Course

Audible pop or tear Acute hemarthrosis and swelling (Cailliet 1991; Brukner & Kahn 2012;
Petty 2012)

Ankle Lateral Ligament Sprain

Ligament pathology Group 2b
[Image] Retrieved from: http:// www.eorthopod.com/sites/default/files/ images/knee_acl_diagnosis01.jpg

Pain (Ingersoll et al., 2008; Petty 2012) Joint tension Subjective experience Instability and knee laxity (Noesberger 1992, Gardinier et al., 2012; Petty
2012)

Mechano-receptor feedback & functional instability Pain avoidance

"

8/21/13

Lateral Ligament Ankle Sprain

Aetiology

A common soft tissue injury The anterior talofibular ligament [ATFL],

Inversion and adduction of a plantarflexed

foot (Struijs & Kerkhoffs, 2010)

The ankle is twisted or turned inwards Lateral ligaments are stretched due to

calcaneofibular ligament [CFL] and posterior talofibular ligament [PTFL] are the major soft tissue stablisers on the lateral aspect of the ankle (Lynch, 2002)
The ATFL is most commonly injured in a

redistribution of body weight (Lynch, 2002)

[Image] Retrieved from http://anklepain.info/wp-content/ uploads/2012/07/sprained-ankle.gif

lateral ligament ankle sprain (Lynch, 2002)

Drake, Vogl & Mitchell (2010)

Grading Lateral Ligament Ankle Sprains

Ankle sprains are graded according to the damage to the ligaments GRADE 1: minor tearing or stretch of ligament tissue, ankle remains

Risk Factors

stable
GRADE 2: partial tearing of ligament tissue, mild instability of the joint,

usually involves damage to 2 ankle ligaments

GRADE 3: complete tearing of 2 or 3 ligaments, significant instability of

joint
(NYU Langone Medical Center, 2013)

(Bahr & Krosshaugh, 2005)

Expected Clinical Course

Management Strategies

Initial localised pain and swelling due to damage to blood vessels (Orthogate, 2006) Ecchymosis/bruising 24-48 hours later (Lynch, 2002) A rapid decrease in pain and improvement in function in the two weeks

REST: avoid placing pressure on the affected ankle ICE: apply ice or cold pack COMPRESSION: wrap an elastic compression bandage ELEVATION: keep ankle raised above the heart level
(NYU Langone Medical Center, 2013)

after the injury (Martin et al., 2013)

The sub-acute phase involves fibroplasia and remodeling and symptoms

including weakness, impaired balance and stiffness (Martin et al., 2013)

Persistent symptoms and signs are associated with mechanical or

functional ankle instability (Martin et al., 2013)

8/21/13

Talar Dome Fractures

Talar dome is the articular surface of the talus (Seiter & Seiter, 2012) It is susceptible to fracture in trauma when the foot is in

dorsiflexion and inversion (Seiter & Seiter, 2012)

Dorsal Dislocation of PIPJ

Ligament pathology Group 2d

In this position the talar dome is forced into the fibula

resulting in a talar dome lesion/fracture (Seiter & Seiter, 2012) sprain

Similar mechanism of injury as a lateral ligament ankle Can occur in conjunction with a ankle sprain but also in

isolation (Judd, 2002)

(Judd, 2002)

Differential diagnoses (eg. palpation, joint integrity tests)

"

Proximal Interphalangeal Joint (PIPJ)

Dorsal injury are the most commonly occurring

Stabilising Factor
Synovial hinge joint

PIPJ injury (Bindra & Foster, 2009 )

Physiological movements: Flexion-

extension
Dorsal dislocation occurs secondary to

hyperextension of PIPJ (Bindra & Foster, 2009 )

Stabiliser Bony congruence Convergence of collateral, accessory

Eaton & Littler classification (Eaton & Littler, 1976):

Type I (Hyperextension) Type II (Dorsal dislocation) Total volar plate avulsion and complete collateral ligament split Type III (Fracture-dislocation)
(Bindra & Foster, 2009) (Bindra & Foster, 2009)

ligament and volar plate at middle phalanx

(Bindra & Foster, 2009)

Laxity of volar plate can lead to hyperextension instability and palmar, dorsal translation (Williams Iv, 2012 )

Risk Factor & Mechanism of Injury

18 year old
Volley-baller High susceptibility to PIPJ injury Dorsal dislocation of PIPJ

Clinical Course
Clinical presentation (Gabel, 2008)
Presence of open wound Acute inflammation, deformity

Internal risk factor:

Age Gender Genetics Psychological state Previous injury

External risk factor:

Event:

Protective equipment Environment Nature of sport

Repetitive violent stress to joint

(Benaglia, Sartorio, & Ingenito, 1996)

Jamming or catching of finger Axial load Extension force

(Bindra & Foster, 2009; Williams Iv, 2012)

Prognosis (Chinchalkar & Gan, 2003)

Good regeneration and remodeling ability Pain steadily reduced after initial 6 months Joint progressively brought to full extension over 3-4 weeks

Adaptation of Bahr & Krosshaugh (2005)

8/21/13

Clinical Course
DDx
Direction of dislocation Visually Subjective questioning: obtain symptomatic and psychosocial
(Franko, n.d.)

Management

information
Simple dislocation / Fracture-dislocation Radiography (AP, Lateral, Oblique) Active/Passive ROM Test Dorsally directed stress testing Positive test: Hyperextension deformity
(Chinchalkar & Gan, 2003; Petty, 2011)

Complications
Adhesions Chronic hyperextension PIPJ flexion contracture Mechanical impact on metacarpo-phalangeal joint
(Chinchalkar & Gan, 2003)

Anterior Lower Leg Contusion

Traumatic contact pathology Group 2a

"

Aetiology
Contusions: commonly known as bruising. (McKeag & Moeller, 2007)

Expected Clinical course

Caused by blunt trauma, does not break the skin. Blood vessels are damaged, resulting in bleeding into the interstitial tissues.

Signs and Symptoms Pain on impact

(McKeag & Moeller, 2007)

Swelling of surrounding tissue

Risk Factors

(McKeag & Moeller, 2007)

Subsequent discoloration of the tissue Site of the contusion may also be firm and tender to the touch Restricted movement
Retrieved from http://ennui.org/lj/ leglump.jpg

Individuals involved in: Manual Labor

High Impact Sport Individuals with bleeding disorders Individuals on anti-coagulants Co-morbid conditions

8/21/13

Expected Clinical course

Healing Process
(Bahr, 2012)

Differential Diagnosis: Compartment Syndrome

Compartment Syndrome
(Heemskere & Kitslaar, 2003).

Takes 2-3 days to fully develop Damaged capillary endothelium releases endothelin, minimizing bleeding Coagulation initiated by von Willebrand factor Discoloration and swelling slowly reduce Change colour from a dark blue or red, to a yellow-green, due to breakdown of

Pressure increase within a muscle compartment Compresses muscles, blood vessels and nerves Develops over a period of hours following a contusion Can lead to permanent injury of the muscle and nerves, or tissue death and amputation

haemoglobin
Lower leg contusions generally heal within 1-2 weeks

If compartment syndrome is suspected, look for the 6 Ps: Pain, parathesia, pallor, paralysis, pulselessness and pressure.

[Image] Retrieved from: drpeggymalone.com

Treatment
RICE
(McKeag & Moeller, 2007)

Rest: Affected limb rested to ensure no further injury. Ice: Apply ice within 24 hours of injury. Compression: May help to reduce swelling in the first 2-3 days. Elevation: To reduce swelling and relieve discomfort. Heat and light massage NSAIDs

Olecranon Bursitis
Traumatic contact pathology Group 2c

"
[Image] Retrieved from http:// www.targetmassage.co.uk

Aetiology
[Image] Retrieved from: http://eorif.com/ olecranon-bursitis-72633

Risk factors

Bursitis (Musculoskeletal medicine for medical students, 2013) Injury (American Society for Surgery of the Hand, 2011; Synecal &Leblan, 2001) Pre-existing medical condition (Show us your hands, 2012; Orthoanswer, 2012) Infection (American Society for Surgery of the Hand, 2011; Medical News Today, 2009)

For injury occupations, sport people, some procedures For medical conditions systemic diseases For infection immune compromised people Social determinants (Health People, 2012) physical environment, occupation Individual determinants (Capital Health, 2010) health, patient compliance

8/21/13

Expected Clinical course

Inflammation process (Loher and Gellman, 2012) Differentiation from osteochondritis dissecans (Harvard Health, 2013; Stubbs, Field,
&Savoie, 2001).

Full movement regained 3-6weeks

[Image] Retrieved from: http://www.assh.org/ Public/HandConditions/Pages/OlecranonBursitis.aspx

[Image] Retrieved from: http://radiology.rsna.org/ content/216/1/207/F11.expansion.html

Abebe, E.S., Moorman, C. D., & Garrett, W. E.(2012). Proximal hamstring avulsion injuries: Injury mechanism, diagnosis and disease course. Operative Techniques in Sports Medicine, 20(1), 2-6. doi:http://dx.doi.org/10.1053/j.otsm.2012.03.001 Ali, K., & Leland, J. M. (2012). Hamstring Strains and Tears in the Athlete. Clinics in Sports Medicine, 31(2), 263-272. doi: http://0-dx.doi.org.alpha2.latrobe.edu.au/10.1016/j.csm.2011.11.001.

Conclusion
Question and answer Assessment Strategy http://stm2013-enquiry1.weebly.com

Almekinders, L. & Maffulli, N. (2007). The Achilles Tendon. London: Springer American Academy of Orthopaedic Surgeons. (2011). Elbow (Olecranon) Bursitis. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00028 American Society for Surgery of the Hand. (2011). Olecranon Bursitis. Retrieved from http://www.assh.org/Public/HandConditions/Pages/Olecranon-Bursitis.aspx Ankle Pain. (2013). Ankle Sprain Symptoms and Categories. Retrieved from http://anklepain.info/ankle-sprain-symptoms-and-categories/ Askling, C, M., Saartok, T. Tengvar, M. Thorstensson, A. (2007). Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics. The American Journal of Sports Medicine.. 35 (10). Retrieved from: http://0-go.galegroup.com.alpha2.latrobe.edu.au/ps/retrieve.do? sgHitCountType=None&sort=RELEVANCE&inPS=true&prodId=EAIM&userGro upName=latrobe&tabID=T002&searchId=R4&resultListType=RESULT_LIST&co ntentSegment=&searchType=AdvancedSearchForm&currentPosition=1&contentSet =GALE|A169614203&&docId=GALE|A169614203&docType=GALE&role= Bahr, R. (2012). The IOC Manual of Sports Injuries: An Illustrated Guide to the Management of Injuries in Physical Activity (1st ed), UK: Wiley-Blackwell. Bahr, R. & Krosshaug, T. (2005). Understanding injury mechanisms: a key component of preventing injuries in sport. British Journal Sports Medicine, 39(6), 324-329

Reference

Benaglia, P. G., Sartorio, F., & Ingenito, R. (1996). Evaluation of a Thermoplastic Splint to Protect the Proximal Interphalangeal Joints of Volleyball Players. Journal of Hand Therapy, 9(1), 52-56. Bindra, R. R., & Foster, B. J. (2009). Management of Proximal Interphalangeal Joint Dislocations in Athletes. Hand Clinics, 25(3), 423-435. doi: http://dx.doi.org/10.1016/j.hcl.2009.05.008 Brukner, P. & Khan, K. (2012). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill. Cailliet, R. (1991). Knee pain and disability. Philadelphia: F.A. Davis. Capital Health. (2010). Determinants of Health. Retrieved from http://www.cdha.nshealth.ca/halifax-community-health-board/population-health/ determinants-health Chinchalkar, S. J., & Gan, B. S. (2003). Management of proximal interphalangeal joint fractures and dislocations. Journal of Hand Therapy, 16(2), 117-128. Clark, M., Lucett, S., & Corn, R. J. (2008). NASM essentials of personal fitness training (3rd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. CliftonSmith, T., & Rowley, J. (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Reviews, 16(1), 75-86. doi: 10.1179/1743288X10Y.0000000025 Cooper, C. (2007). Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity. St. Louis: Mosby Elsevier. Cortiva. (2006). The pectoralis minor story. Retrieved from http://www.learnmuscles.com/ DeepMTR-Jun-2006.pdf

Drake, R. L., Vogl, W. & Mitchell, A. W. (2010). Grays anatomy for students (2nd ed.). Churchill Livingston, Elsevier Eaton, R. G., & Littler, j. W. (1976). Joint Injuries and their sequelae. Clinics in Plastic Surgery, 3(1), 85-98. eORIF. (2012). Olecranon Bursitis 726.33. Retrieved from http://eorif.com/olecranon-bursitis-72633

Reference

Reference

Franko, O. I. (n.d.). [Image]Dislocation Reduction of the PIP and DIP Joint. (T. W. Thomsen, G. S. Setnik, & C. S. Day, Eds.) Retrieved from https:// www.proceduresconsult.jp/Home/ProcedureListing/ProcedureDetails/tabid/74/c/ 451/language/en-US/Default.aspx Gabel, G. T. (2008). Sports Medicine. In C. Nofsinger, B. Bach & D. Drez (Eds.), (pp. 72-74): Cambridge University Press. Gardinier, E. S., Manal, K., Buchanan, T. S., & Snyder-Mackler, L. (2012). Gait and neuromuscular asymmetries after acute anterior cruciate ligament rupture. Medicine and Science in Sports and Exercise, 44(8), 1490-1496. doi:10.1249/MSS. 0b013e31824d2783. Harvard Health Publications. ACL (anterior cruciate ligament) injuries. (2010). Norwalk: Belvoir Media Group, LLC. Retrieved from http://0-search.proquest.com.alpha2.latrobe.edu.au/docview/1401156630? accountid=12001 Harvard Health Publications. (2013). Bursitis. Retrieved from http://0-search.proquest.com.alpha2.latrobe.edu.au/docview/1370740785 Healthy People. (2012). Determinants of Health. Retrieved from http://www.healthypeople.gov/2020/about/DOHAbout.aspx

10

8/21/13

Heemskere, J. & Kitslaar, P. (2003). Acute Compartment Syndrome of the Lower Leg: Retrospective Study on Prevalence, Technique, and Outcome of Fasciotomes, World Journal of Surgery, 27 (6): 744-747. Hess, G. W. (2010). Achilles Tendon Rupture: A Review of Etiology, Population, Anatomy, Risk Factors, and Injury Prevention. Sage Journals 3(1), 29-32. doi: 10.1177/1938640009355191 Hunter, D, G., (2007). The assessment and management of chronic hamstring/posterior thigh pain. Best Practice & Research Clinical Rheumatology. 21 (2). 261-274. doi:10.1016/ j.berh.2006.12.002 Ingersoll, C. D., Grindstaff, T. L., Pietrosimone, B. G., & Hart, J. M. (2008). Neuromuscular consequences of anterior cruciate ligament injury. Clinics in Sports Medicine, 27(3), 383-404. doi:10.1016/j.csm.2008.03.004. Judd, D. B. (2002). Foot fractures frequently misdiagnosed as ankle sprains. American Family Physician, 66(5), 785-795. Retrieved from http://www.aafp.org/afp/ 2002/0901/p785.html Kishan. G., Sekhar, G., Neil, A. (2008). Hamstring injuries. Trauma. 10 (4). 271-279. Retrieved from: http://0-search.proquest.com.alpha2.latrobe.edu.au/docview/223621725 Lewis, J. S., & Valentine, R. E. (2007). The pectoralis minor length test: a study of the intra-rater reliability and diagnostic accuracy in subjects with and without shoulder symptoms. BMC Musculoskeletal Disorders, 8(1), 64-74. doi: 10.1186/1471-2474-8-64 Ligh, C. A., Schulman, B. L., & Safran, M. R. (2009). Case Reports: Unusual Cause Of Shoulder Pain In A Collegiate Baseball Player. Clinical Orthopaedics and Related Research, 467(10), 2744-2748. doi: 10.1007/s11999-009-0962-z

Loher, K. M., & Gellman, H. (2012). Bursitis Pathophysiology. Retrieved from http://emedicine.medscape.com/article/2145588-overview#a0104 Lynch, S. A. (2002). Assessment of the Injured Ankle in the Athlete. Journal of Athletic Training, 37(4), 406-412. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164372/pdf/attr_37_0_0406.pd Martin, R. L., Davenport, T. E., Seth, S. P., Wukich, D. K. & Godges, J. J. (2013). Ankle Stability and Movement Coordination Impariments: Ankle Ligament Sprians. Retrieved from http://www.orthopt.org/uploads/content_files/ICF/Updated_Guidelines/ Ankle_Sprain_CPG___2013_06_30_version.pdf Mayo Clinic. (2011). Bursitis. Retrieved from http://www.mayoclinic.com/health/bursitis/DS00032/DSECTION=tests-anddiagnosis Mayo Clinic. (2012). Osteochondritis dissecans. Retrieved from http://www.mayoclinic.com/health/osteochondritis-dissecans/DS00741/ DSECTION=tests-and-diagnosis Mayo Clinic. (2013). Thoracic outlet syndrome. Retrieved from http:// www.mayoclinic.com/health/thoracic-outlet-syndrome/DS00800/ DSECTION=symptoms McFarland, E. G., & Peterson, S. A. (n.d.). Sports Medicine and Shoulder surgery. Retrieved from http://www.hopkinsortho.org/orthopedicsurgery/bursitis.html McKeag, D. & Moeller, J. (2007). ACSM's Primary Care Sports Medicine (2nd ed). Philadelphia: Lippincott Williams & Wilkins.

Reference

Reference

Medical News Today. (2009). What is bursitis? What causes bursitis?. Retrieved from http://www.medicalnewstoday.com/articles/152120.php MedlinePlus, National Institutes of Health. (2013). Bursitis. Retrieved from http://www.nlm.nih.gov/medlineplus/bursitis.html Micheo, W., Hernndez, L., & Seda, C. (2010). Evaluation, management, rehabilitation, and prevention of anterior cruciate ligament injury: Current concepts. PM & R : The Journal of Injury, Function, and Rehabilitation, 2(10), 935-944. doi:10.1016/j.pmrj. 2010.06.014 Musculoskeletal medicine for medical students. (2013). Olecranon Bursitis. Retrieved from http://www.orthopaedicsone.com/display/MSKMed/Olecranon+bursitis Nandra, R. S., Matharu, G. S., & Porter, K. M. (2011). Acute Achilles tendon rupture. Sage Journals, 14(1), 67-81. doi: 10.1177/1460408611415909 National Institutes of Health. (2012). Hamstring Strain Aftercare. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000551.htm Nicholas, A. W. (2009). Diagnosis and management of thoracic outlet syndrome. Current sports medicine reports, 8(5), 176-183. doi: 10.1007/s11936-009-0018-4 Noesberger, B. (1992). Diagnosis, Pathomechanics, and Pathomorphology of Anterior Cruciate Ligament Insufficiency. In Jakob, R., Stubli, H., & Schweizerische Gesellschaft fr Orthopdie. Orthopdische Arbeitsgruppe Knie. (1992). The knee and the cruciate ligaments: Anatomy, biomechanics, clinical aspects, reconstruction, complications, rehabilitation. New York: Springer-Verlag

Opar, D. A., Williams, M. D., & Shield, A. J. (2012). Hamstring strain injuries.Sports Medicine,42(3), 209-226. doi:http://dx.doi.org/10.2165/11594800-000000000-00000 Orchard, J, W., Farhart, P., Leopold, C., (2004). Lumbar spine region pathology and hamstring injuries in athletes: is there a connection?. Br J Sports Med. 38 (4). 502-504. doi: 10.1136/bjsm.2003.011346 Orthoanswer, (2012). Olecranon Bursitis Causes. Retrieved from http://orthoanswer.org/shoulder-arm-elbow/olecranon-bursitis/causes.html Orthogate. (2006). Ankle Sprain and Instability. Retrieved from http://www.orthogate.org/ patient-education/ankle/ankle-sprain-and-instability.html Paavola, M., Kannus, P., Jrvinen, T. A. H., Khan, K., Jzsa L. & Jrvinen, M. (2002). Achilles Tendinopathy. The Journal of Bone & Joint Surgery 84-A(11), 2062-2076. Retrieved from http://jbjs.org/data/Journals/JBJS/839/JBJA084112062.pdf Papoutsidakis, A. (2011). Predisposing factors for anterior cruciate ligament injury. British Journal of Sports Medicine, 45(2), e2-e2. doi:10.1136/bjsm.2010.081570.5 Petty, N. (Ed.). (2011). Neuromusculoskeletal examination and assessment: a handbook for therapists. London, UK: Elsevier. Rondeau, M. W., Padua, D. A., Thigpen, C. A., & Harrington, S. E. (2012). Precision and validity of a clinical method for pectoral minor length assessment in overheadthrowing athletes. Athletic Training & Sports Health Care, 4(2), 67-72. doi: 10.3928/19425864-20110630-01

Reference

Reference

Ropiak, C, R., Bosco, J, A,. (2012). Hamstring Injuries. Bulletin of the NYU Hospital for joint diseases. 70 (1). 41-48. Retrieved from: http://0-search.proquest.com.alpha2.latrobe.edu.au/docview/1223499076/ fulltextPDF?accountid=12001 Seiter, J.L., Seiter Jr, K. P. (2012). Osteochondral Talar Lesions and Defects. Clinics in Podiatry and Medicine and Surgery, 29(4), 483-500. doi: 10.1016/j.cpm.2012.08.009

Reference

Show us your hands. (2012). Understanding Inflammatory Arthritis. Retrieved from http://www.showusyourhands.org/resources/ Simons, D. G., Travell, J. G., & Simons, L. S. (1999). Pectoralis Minor Muscle. Travell & Simons' myofascial pain and dysfunction: the trigger point manual (2nd ed., pp. 844-861). Baltimore: Williams & Wilkins. Struijs, P. A., & Kerkhoffs, G. M. (2010). Ankle sprain. Clinical evidence. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907605/pdf/2010-1115.pdf Stubbs, J.M., Field, D.L., Savoie, H.F. (2001). Osteochondritis Dissecans of the Elbow. Arthroscopic Surgery for Athletic Elbow and Wrist Injuries, 20(1), Jan. Synecal, L. and Leblanc, M. (2001). Olecranon bursitis in chronic haemodialysis patients. Nephrology Dialysis Transplantation, 16(9), 1956-1957. doi: 10.1093/ndt/16.9.1956 Williams Iv, C. S. (2012). Proximal Interphalangeal Joint Fracture Dislocations: Stable and Unstable. Hand Clinics, 28(3), 409-416. doi: http://dx.doi.org/10.1016/j.hcl.2012.05.036

11