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Glenohumeral Extension on the Dip: Considerations for the Strength and Conditioning Professional

by | Nov 10, 2021 | Health Tips

by Nick Mattis, SPT

Introduction:

The glenohumeral joint (shoulder) has a high level of mobility which comes at a price of low stability. Due to the extensive range of motion of the shoulder, the shoulder is not as stable as several other joints in the body (i.e. elbow, knee). Passive stabilizers of the glenohumeral joint include which of the following? There are several passive stabilizers of the joint such as the glenoid labrum, the ligamentous structures, and the bony articulation of the joint (2). Active stabilizers of the glenohumeral joint include which of the following? Then there are active stabilizers of the joint such as rotator cuff muscles, deltoid, biceps brachii, and latissimus dorsi. These active stabilizers are able to contract to assist with keeping the humeral head in the glenoid fossa. Active and passive stabilizers can become strained/torn/ruptured when the humeral head enters abnormal positioning outside the center of the glenoid cavity. During the dip exercise the humerus often reaches the end range of extension and can place the humeral head in an abnormal position. Which of the following describes the movement of the humeral head at the end of a range of movement during a dip exercise? As the humerus rotates posteriorly as the arm goes back, the head of the humerus translates anteriorly. To keep the humerus from slipping out of the glenoid cavity, the active and passive stabilizers resist excessive anterior movement of the humeral head. The main active stabilizer preventing the excessive anterior translation in the dip is the clavicular head of the Pectoralis Major (PM). The passive stability to the anterior translation is produced by the Anterior Band of the Inferior Glenohumeral Ligament (AB-IGHL). During the dip exercise, which of the following tissues are of particular concern regarding injury and subsequent lack of joint stability? The PM and the anteroinferior joint capsule are the tissues of highest concern to be injured. The Pectoralis Major and the AB-IGHL receive the highest amount of stress on them in the bottom of the dip position. Damage to these structures can result in Anterior Instability of the glenohumeral joint.

Pectoralis Major:

Damage to the PM can result in a strain of the muscle. The clavicular head of the PM is assists in flexion of the GH joint. Which muscle is responsible for controlling the depth of the movement during the dip exercise? When performing a dip, this portion of the PM is actively elongating to eccentrically control the speed and depth at which the dip is performed. Glenohumeral movements that are at the highest risk of injury include which of the following three events? There have been three risk factors identified that can result in injury of the PM: 1) external rotation of the shoulder while in the end range of extension, 2) moderate to maximal loads placed on the PM, 3) eccentric contraction of the muscle (3).

Anterior Shoulder Instability:

Anterior Instability (AI) occurs when there is laxity either the active and/or passive stabilizers on the anterior surface of the GH joint. This can result in an anterior dislocation or subluxation of the joint. Repetitive loading of the passive AB-IGHL (performing dips frequently at high loads) can result in deformation of the ligament and lead to AI due to the excessive load at end ranges of extension combined with and externally rotated positioning. Similarly, injury to the active stabilizers can also result in AI. During exercise when the humeral head is pushed forward (anteriorly), which of the following rotator cuff muscles is responsible for actively contracting to resist this movement? The subscapularis and teres minor of the rotator cuff are recruited in end ranges of extension to reduce the amount of anterior translation of the humeral head.

The Dip:

Which of the following accurately describes the dip exercise? The dip is classified as a closed-kinetic-chain exercise that is performed at body weight, with the use of a band to reduce body weight, or the addition of a weight belt to add body weight. When considering the potential risk of injury during and prescription of the dip exercise, which of the following is recommended by the authors? Tips for the prescription of dips include limiting the depth of the dip to avoid the end range positon to reduce stress placed on the PM and AB-IGHL. The authors recommend within session programming variation for the purpose of? Repetitions, load, frequency, and rest time should all be managed and to reduce muscular fatigue. Reducing muscular fatigue will prolong the technique of the dip. Poor technique can often result in the 3 risk factors mention before that result in the highest risk of injury.

Physical Therapy First:

Here at Physical Therapy First, our team of skilled therapists are able to assist you in the recovery from shoulder instability. Through manual techniques and other interventions, we can restore your ROM, increase strength, and return you back to activity. Your therapist can help you properly decide whether exercises such as the dip are appropriate for you based on your individual functional needs.  Call today to schedule an appointment.

References:

1) McKenzie, Alec K. BClinSci; Crowley-McHattan, Zachary J. PhD; Meir, Rudi PhD, CSCS; Whitting, John W. PhD; Volschenk, Wynand BA (HMS Hons) Sports Science, CSCS Glenohumeral Extension and the Dip: Considerations for the Strength and Conditioning Professional, Strength and Conditioning Journal: February 2021 – Volume 43 – Issue 1 – p 93-100 doi: 10.1519/SSC.0000000000000579

2) Terry GC, Hammon D, France P, Norwood LA. The stabilizing function of passive shoulder restraints. Am J Sports Med 19: 26–34, 1991.

3) Provencher CMT, Handfield K, Boniquit NT, et al. Injuries to the pectoralis major muscle: Diagnosis and management. Am J Sports Med 38: 1693–1705, 2010.

Jogging After Total Hip Arthroplasty

by | Nov 1, 2021 | Health Tips

by Ray Moore  PT, DPT, OCS, FAAOMPT

Introduction

Total hip arthroplasty (THA), otherwise known as total hip replacement, is a common surgery performed to relieve pain in patients with hip osteoarthritis. Hip replacements have been well documented as successful procedures with good long-term outcomes. Patient’s expectations of hip replacements have increased, with many patients desiring to return to high levels of activity following hip replacements. There is a lack of consensus among orthopedic surgeons regarding what levels of athletic activity should be allowed or recommended after a hip replacement. According to Healy et al,2,3 jogging is classified as a “high-impact” and “not recommended” activity following hip replacements due to the high hip contact forces generated. However, jogging is known to have significant health benefits, including improving cardiovascular endurance and strength. Jogging is generally recommended for people with several different health conditions, including cardiovascular disease, however research on the benefits and risks of jogging post-hip replacement is lacking.

There is limited research on jogging after hip replacements and the impact on component survival. There is also limited research on participation rates, jogging parameters, and the reasons people choose not to participate in jogging post-hip replacement. The authors state that the purpose of this study is to investigate the number of patients who participated in jogging after a hip replacement, the reasons given by those who were interested in but did not participate in jogging, the parameters surrounding post-operative jogging, short-term clinical and radiographic results for post-operative joggers, and factors related to post-operative jogging.

Participants

This study included 804 hips from 608 patients who underwent primary total hip replacements at two separate hospitals. The patients who answered a self-completed questionnaire during a routine follow-up visit were included in the study.

  • 804 hips from 608 total patients (85 men and 523 women):
    • Mean age: 62 years (range: 26-98 years)
    • Mean body mass index (BMI): 23.2 (range: 14.7-34.2)
    • Mean post-operative follow-up duration: 4.8 years (range: 2.3-7.8 years)
    • Bilateral hip replacement (both hips): 196 patients
    • Unilateral hip replacement (one hip): 412 patients
    • Hip resurfacing arthroplasty (HRA): performed in 97 hips of 81 patients
    • Conventional total hip arthroplasty (THA): performed in 707 hips of 527 patients

Methods

Participants were selected from two local participating hospitals after filling out a survey at a routine follow-up appointment. Participants underwent either bilateral (both hips) or unilateral (one hip) total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA) procedures. Several different HRA and THA components were used per surgeon’s choice in each patient as listed in the article. Five patients were excluded from the study due to other medical reasons or declining the survey. The post-operative rehabilitation protocol is as follows below:

  • Post-Operative Rehabilitation Protocol
    • All patients were allowed to walk with full weightbearing on post-operative day 1
    • Most patients could walk without a cane at post-operative week 1-3
    • Most patients returned to usual daily activities at post-operative month 1
    • Patients who wanted to jog were allowed to do so at 6 months post-operatively
    • Patients were also allowed to participate in sports activities at 6 months post-operatively, with the exception of contact sports and martial arts (soccer, baseball, basketball, volleyball, rugby, judo, and karate)

All patients were asked to give information about pre-operative and post-operative jogging habits. Those who jogged after their hip replacement answered additional questions about jogging frequency, distance, duration, velocity, and symptoms. Those who did not jog after their hip replacement were asked to provide reasons as to why they did not. Patients were asked to complete two questionnaires: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) self-assessment questionnaire for pain, stiffness, and physical function (higher score indicates worse pain, stiffness, and physical function) and University of California-Los Angeles (UCLA) activity scale (higher score indicates higher activity levels). The researchers evaluated serial radiographs (X-rays) to identify any implant loosening, weight-bearing wear, and bone degeneration around the components.

Results

Of the 608 patients, 33 patients (5.4%) were habitual pre-operative joggers and 23 (3.8%) continued habitual post-operative jogging. The 23 post-operative jogger group was comprised of 13 men and 10 women with mean age of 57 +/- 12 years. Ten of 81 patients (12.3%) who underwent hip resurfacing and 13 of 527 patients (2.5%) who underwent hip replacement regularly participated in post-operative jogging. Post-operative jogging was performed on average 4 times per week (range: 1-7 times per week) for a distance of 3.6 km (range: 0.5-15 km) over a duration of 29 minutes (range: 5-90 minutes) with a velocity of 7.7 km/hour (range: 3-18 km/hour). Additionally, 5 of 23 patients (21.7%) regularly jogged more than 10 km/week.

Of the 585 patients who did not participate in post-operative jogging, 511 (87%) stated they had no interest and 74 patients (13%) stated they are interested in jogging but do not currently. Reasons provided by the non-jogging group were anxiety (45 patients, 61%), that jogging was impossible because of pain, decreased range of motion, and muscle weakness (18 patients, 24%), and low back or knee pain (11 patients, 15%).

On the WOMAC questionnaire, joggers had significantly lower mean scores (which is more desirable) of both pain and physical function than non-joggers, with no significant difference in stiffness between the two groups. On the UCLA activity score, joggers had significantly higher scores (which is more desirable) than non-joggers. Of the jogging group, no patients complained of pain during post-operative jogging, no patient’s hips showed evidence of osteolysis, implant loosening, abnormal component migration, or excessive wear at an average 5-year follow-up on X-ray imaging, and no patient had a history of post-operative hip dislocation.

Summary

In this research study, 3.8% of total hip replacement patients participated in post-operative jogging. This study found no negative influences of jogging on implant survival at a short-term post-operative follow-up. The findings of this study do have some limitations, as stated in their conclusion section. One notable limitation is that this study had a short follow-up period of an average of 4.8 years, therefore additional research is needed to understand the longer-term effects of jogging on total hip replacements. Additional key findings include that 65.2% of post-operative joggers were not pre-operative joggers. The most common reason for avoiding post-operative jogging was anxiety, which could hopefully be improved through education and more definitive guidelines on post-hip replacement activity participation and safety.

At Physical Therapy First, our goal is to assist members of our community in returning to their desired activity level and improving quality of life.  Our physical therapists are trained to assist patients maximize their post-operative performance which may include jogging for previous runners.  Returning to higher impact activities will depend on the individual’s recovery in conjunction with their surgeon’s recommendations.  In conclusion, at short-term follow-up participation in post-operative jogging did not lead to any significant poor outcomes in patients with total hip replacements. Longer follow-up periods are needed to fully understand the effects of habitual jogging on hip replacements.

References

  1. Abe H, Sakai T, Nishii T, Takao M, Nakamura N, Sugano N. Jogging after total hip arthroplasty. Am J Sports Med. 2014;42(1):131-137. doi:10.1177/0363546513506866
  2. Healy WL, Iorio R, Lemos MJ. Athletic activity after joint replacement. Am J Sports Med. 2001;29(3):377-388. doi:10.1177/03635465010290032301
  3. Healy WL, Sharma S, Schwartz B, Iorio R. Athletic activity after total joint arthroplasty. J Bone Joint Surg Am. 2008;90(10):2245-2252. doi:10.2106/JBJS.H.00274

 

Factors predicting outcomes in whiplash injury: a systematic meta-review of prognostic factors

by | Oct 25, 2021 | Health Tips

by Mark Boyland, PT, DPT

This meta-analysis explored the prognostic factors which can predict outcomes for patients with acute whiplash injuries.  As a disclaimer this study was meant to identify the factors only and not what scales or intensity would lead to prognostic factors.  The authors note that it is beyond the scope of their study to examine specific quantitative data regarding prognosis.  This concept will be discussed later in this summary.  I had two major takeaways from this piece: 50% of people who suffer from whiplash will have long term negative impacts, and that whiplash related pain and anxiety after a car accident are the most consistent prognostic factors for having long term negative impacts on their function.  Other factors that were prognostic included catastrophizing, compensation and legal factors, and early use of health care.  The authors did not identify what levels of pain or anxiety were more prognostic.  The authors did not identify the amount of compensation or specific measures of legal factors.  While a knee jerk reaction may be to say that people who have significant pain and anxiety who also get legal counsel quickly involved will have long term disability but that was not the focus of this paper and this assumption cannot be made based on the information provided.  Please read on to find out what factors were not associated with long term impact or required further research to establish the type of connection.

This meta-analysis was relatively sizeable in terms of the amount of studies analyzed and the number of patients which were included across all studies reviewed.  The authors analyzed 12 systematic reviews of moderate quality.  Each systematic review analyzed anywhere from 6 to 38 studies for a total of 200 studies which included over 99,000 patients.  The studies examined ranged from 1980-2012 and the meta-analysis was published in a 2017 journal.  Being able to look at over 20 years of research and explore nearly 100,000 patients is an achievement and does bring a little more merit to a relatively common population.

The study was funded by the Motor Accident Authority (MAA) of New South Wales, Australia.  However, the funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.  So why study acute whiplash injuries?

Whiplash is among the leading car crash related injuries in terms of burden on patients, to the healthcare system, and on insurance organizations.  Whiplash type injuries have been increasing over the past decade, and patterns of car accidents that causes whiplash have also changed and now include minor types of accidents.  The overall increase in whiplash may also be due to rise in traffic density and changes in societal and litigation factors but was not part of this paper’s exploration.  The authors examined potential prognostic factors and separated these factors into 4 categories: associated, non associated, lack of evidence, and controversial.  Associated factors were defined as those which found adequate evidence to conclude that a factor was associated with the outcome of acute whiplash injury.  Non associated was the opposite.  A lack of evidence was unable to identify adequate evidence regarding a prognostic factor.  Controversial factors were those which had conflicted evidence.

As mentioned earlier, the authors found the following as associated factors for predicting outcomes: post injury pain and disability, post-injury anxiety, catastrophizing, compensation and legal factors, early use of health care.  The most consistent finding was the association of post injury pain and disability with long term pain and disability.  The association of other factors was not as strong although the association of psychosocial factors with whiplash is notable.

Interestingly enough post injury MRI/X-ray findings, motor dysfunctions, or factors related to the collision were not associated with continuation of pain and disability in patient’s whiplash.  Factors related to the collision were more related to speed of collision or direction of impact.

However, evidence on demographics and 3 psychological factors and prior pain was conflicting and there is a shortage of evidence related to the significance of genetic factors.

Overall this meta review suggests an association between initial pain and anxiety and the outcome of acute whiplash injury, and less evidence for an association with physical factors.  To critically re-emphasize, this paper only sought to identify prognostic factors but not the scales or intensity of these factors.  This would be an opportunity for additional research.  There is a limited number of studies which examines prognosis of whiplash based on: occupation type, disc degeneration, pre-existing /new widespread body pain/fibromyalgia, or pre-injury fitness or exercise levels.  As humans we are incredibly complex individuals when you consider what makes us ‘us’ and to determine consistent patterns that can fit specific populations is difficult.  While the findings of this paper are unsurprising that having whiplash related pain is a factor for long term whiplash related pain, being able to identify factors which are not prognostic is also helpful.

Article Review: Alternative and Complementary Therapies in Osteoarthritis and Cartilage Repair

by | Oct 18, 2021 | Health Tips

by Tyler Tice PT, DPT, ATC

Introduction:

Osteoarthritis (OA) is very prevalent within the global population and is becoming a growing socioeconomic and public health issue. OA is when joints undergo changes in which cartilage becomes thin and sometimes can be lost which can create bony changes in the joints and cause pain and functional weaknesses. The most common body parts that OA occurs in are the knees, distal interphalangeal joints (fingers), and hips. Clinically, OA can cause joint pain, stiffness, functional deficits, and reduced quality of life. There are multiple interventions for joint OA, however there are is no direct advice on “alternative” treatments including autologous chondrocyte implantation (ACI), autologous/heterologous mesenchymal stem cells (MSCs), platelet rich plasma (PRP), Vitamin D supplements, and other therapies. This study reviewed the current literature on the above mentioned “alternative” therapies to evaluate the research that has been done and make conclusions to determine the effectiveness of them.

Autologous Chondrocyte Implantation (ACI):

ACI is a surgical intervention where cartilage is removed from the affected area, cells of that cartilage (chondrocytes) are cultured, and then injected back into the affected cartilage location under a flap or membrane that is sutured into the defect.

Early trials found no benefit of ACI, however ACI has improved to include matrix assisted ACI (MACI). MACI has shown to have better outcomes than microfracture in terms of clinical and functional outcomes, however no differences with MRI or histological outcomes. ACI is also considered a high cost treatment and although there may be short term clinical benefits, the long term benefits are unknown. It is concluded that MACI may be a good use for symptomatic therapy in early cartilage disease and traumatic cartilage lesions, though may not be beneficial in OA.

Autologous Mesenchymal Stem Cells (MSCs)

Mesenchymal stem cells (MSCs) are cells from the bone marrow that can help facilitate the repair of chondral defects, or joint cartilage defects. MSCs can be directly injected into a joint where they can differentiate into either cartilage, bone, or fat and display anti-inflammatory properties. Based off the research, MSCs can be effective with lowering pain related to chondral defects or joint OA. However, there is limited evidence to suggest improvements with structural/ tissue repair. There are also multiple sources where autologous MSCs can be derived from including bone marrow, adipose (fat) tissue, synovial membrane, umbilical cord MSCs, and peripheral blood and there are various techniques to prepare the MSCs. Also, MSCs seem to have a greater positive impact on individuals who are younger in age, male, low BMI and have a small lesion/defect at mild to moderate OA severity. Despite potential benefits of MSCs to help decrease pain, there are multiple factors limiting stem cell efficacy and a standardization of MSC interventions is needed to obtain a better understanding and a clearer conclusion.

Platelet-rich Plasma (PRP)

Platelets are part of our blood that play an important role in inflammation. Platelet rich plasma is a fluid that helps stimulate cell growth, cell migration, and synthesis of our extracellular matrix. PRP is derived from centrifuging our blood so that the plasma component which is rich in platelets is separated from the other components of our blood. This plasma component is then extracted and injected back into our affected joint to help stimulate cell growth. PRP varies widely in regards to preparations and formulations making it challenging to determine effectiveness of PRP when injected into joints with OA, though some trial studies support a symptomatic benefit.

Vitamin D

There are receptors for Vitamin D on chondrocytes and Vitamin D stimulates proteoglycan synthesis which are both important for cartilage health. Vitamin D deficiency influences bone remodeling which may predispose joints to the development of OA. Based on this info above, it is believed that increasing Vitamin D may improve cartilage structure and help slow down progression of joint OA. However, studies conducted demonstrate no structural or symptomatic benefit in OA.

Other Therapies:

Collagens: Oral and intra-articular

Oral and intra-articular collagens are a rich source of amino acids and can be helpful in OA to stimulate the joint to produce collagens. Even though this is widely used across the world, the current data does not support a positive recommendation to treat OA patients, however may have a mild effect on pain and function.

Methylsulfonylmethane (MSM)

This is a dietary supplement found in plants, fruits, and vegetables. Only small trials have researched the effectiveness of MSM and although MSM is a safe supplement, larger, better designed trials are needed to make more conclusive recommendations.

S-adenosylmethionine (SAMe)

This is produced in the liver and has been researched on the effectiveness for treating hip and knee OA. The research showed a minor improvement with pain and function when treating OA with SAMe compared to placebo. However, the quality of the studies were poor suggesting it is difficult to make accurate conclusions.

Curcuma

Curcuma is an extract of turmeric which has roots in Ayurvedic and Chinese medicine as an anti-inflammatory agent. In a meta-analysis from 2016, improvements in symptoms and NSAID consumption were observed for individuals that used curcuma vs placebo, however curcuma did no better when compared to Ibuprofen or when added to Dicflofenac. Another meta analysis published in 2018 concluded that curcuma improved pain and function when compared to placebo, however evidence was not enough at the time to be considered a recommendation to clinically treat OA.

Harpagophytum

This is an African plant thought to have anti-inflammatory properties. A systematic review concluded there was moderate evidence to help treat low back pain and joint OA. However, there were only three studies included and additional research is needed before it can be recommended in clinical practice.

Ginger

This is another therapy that is thought to have an anti-inflammatory effect. A systematic review and meta-analysis of the studies performed found a significant reduction in pain and disability when using ginger vs placebo. However, there were high rates of discontinuation when taking ginger and may have increased risk of mild gastro-intestinal adverse effects.

It is challenging to make accurate conclusions of the clinical effectiveness of these interventions on symptomatic OA due to issues with study design and limited amount of research. Some interventions may be beneficial and there is insufficient evidence to declare them completely ineffective. Therefore, all of these interventions need to be further researched with larger, more appropriately designed studies.

Reference:

Fuggle NR, Cooper C, Oreffo ROC, et al. Alternative and Complementary Therapies in Osteoarthritis and Cartilage Repair. Aging Clinical and Experimental Research. 2020, 32:547-560

The Importance of Force Couples In our Shoulders

by | Oct 11, 2021 | Health Tips

by Tyler Tice, PT, DPT, MS, ATC
Force couples are when 2 or more muscles on opposing sides of a joint work together to provide joint stability or create movement. In the shoulder joint, there are three important force couples that help move and control our shoulders. When these force couples are not working properly, it can lead to pain and injury.

1. Deltoid-rotator cuff force couple:

  • Produces largest amount of force
  • Rotator cuff muscles: supraspinatus, infraspinatus, teres minor, subscapularis
  • When raising arm overhead, the deltoid causes an UPWARD and OUTWARD force on the humerus (upper arm bone) during the first part of the motion
  • 3 of the rotator cuff muscles (infraspinatus, teres minor, subscapularis) collectively create a DOWNWARD and INWARD force on the humerus to maintain the proper positioning of the ball in its socket.
  • The supraspinatus creates a compressive force to help keep the humerus in proper positioning. When rotator cuff muscles are not working properly, this can cause greater amount of UPWARD and OUTWARD movement at the shoulder potentially causing more pressure on the humeral head as well as potentially leading to injury of other shoulder structures

2. Upper trapezius and serratus anterior force couples

  • To produce upward rotation of the scapula, or shoulder blade when raising our arms
  • 4 major muscles: Serratus anterior, Lower trapezius, Upper Trapezius, Levator Scapula
  • 4 important functions: Allows for rotation of the shoulder blade to keep the glenoid (socket of the shoulder) in proper positioning; Maintains proper length-tension relationship for the deltoids; Prevents impingement on the rotator cuff muscles; Provides stable scapular base for proper muscular recruitment
  • Collectively, these 4 muscles act on the shoulder blade creating forces at different aspects of the shoulder blade in different directions where the end result becomes UPWARD ROTATION of the shoulder blade
  • The serratus anterior and lower trapezius are the primary stabilizers of the shoulder blade when the arm is raised 90 degrees or more out to the side
  • We need proper shoulder blade upward rotation to maintain shoulder stability when raising our arm to the side. It has been shown with shoulder impingement syndrome that there is decreased activity of serratus anterior, delay in activating lower trapezius, and overactivity of upper trap and levator scapula.

3. Anterior-posterior rotator cuff force couples

  • Anterior (front) rotator cuff: subscapularis
  • Posterior (back) rotator cuff: infraspinatus and teres minor
  • Create a DOWNWARD stability within shoulder and contribute to compressive forces to maintain the humeral head within the socket when elevating arm
  • Subscapularis (front) and infraspinatus (back) pull DOWNWARD and INWARD at about 45 deg angle; teres minor (back) pull DOWNWARD and INWARD at about 55 deg angle to keep shoulder centered in joint
  • It is common that the shoulder internal rotator muscle groups, which includes the subscapularis are more developed compared to the teres minor and infraspinatus creating a potential force couple imbalance leading to potential lack of stability.

(picture on right demonstrates this)

Reference:

Ellenbecker T, Manske R, Kelley, M. Current Concepts of Orthopaedic Physical Therapy: The Shoulder: Physical Therapy Patient Management Using Current Evidence. 4th Edition. Orthopedic Section, APTA 2016