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By: Bertram G. Katzung MD, PhD

  • Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco

http://cmp.ucsf.edu/faculty/bertram-katzung

Statistical analysis included descriptive statistics using frequency and cross tabulation tables and bar charts order 20 mg micardis fast delivery heart attack diet. Inferential statistics using Pearson’s correlations (Cortinhas and Black 2012: 489) at a significance level of 0 cheap micardis 20 mg line heart attack blood test. The testing of the hypotheses was performed using Fisher’s Exact tests (Daniel 2010: 629) for nominal data and ordinal data at a level of significance of 0 order micardis 80 mg visa blood pressure chart free printable. The statistical analysis also included Mantel-Haenszel Common Odds Ratios (Daniel 2010: 643 buy 80mg micardis mastercard pulse pressure change during exercise. It will be presented using the following categories: Participation rate; participant demographics; injury prevalence; balance data, comparisons and correlations. Each objective will be included in its appropriate section to ease the flow of information. Of the original list of 80 participants, 12 participants (15%) were eliminated from the study due to non-compliance leaving a total of 68 participants (85%. The original sample was made up through the recruitment of an additional 12 participants who met the inclusion criteria, bringing the final participation rate to 100%. More than one fifth of the participants were overweight making up 22% of the uninjured and 23% of the injured groups. The majority of the participants who sustained injuries reported just one injury (16%) (Table 4. These injuries were reported by six participants with each body part making up 27. The combinations of injury mechanisms included landing/running/collision with a player, running/overuse, tackle/collision with a player, tackle/landing/running, tackle/overuse/kicking ball and tackle/turning/collision with a player/kicking ball. These four assessments involved each participant standing on a firm surface with eyes open, standing on a firm surface with eyes closed, standing on a soft foam surface with eyes open and standing on a soft foam surface with eyes closed. A higher percentage of injured participants performed poorly in the assessment involving eyes open and standing on a soft foam surface as opposed to the uninjured participants. Risk of Injury the risk estimate for injury is shown in the odds ratio in Table 4. Participants were challenged to move through a movement pattern consistent with the sway envelope. The goal score is 65 and above for all conditions except backward direction control which is 30. Dynamic balance in the backward direction was acceptable for both injured and uninjured participants with the uninjured participants scoring higher than the injured participants. A higher relative percentage of injured participants performed poorly in the assessment involving right, left, forward-right, backward-right and backward-left direction control. Risk of Injury the risk estimate for injury is shown by the odds ratio in Table 4. However, despite the significant p values exhibited, the r values indicated a weak to low degree of correlation. This was representative of the five high school grades in South Africa (Grades 8-12) (South African Department of Basic Education 2012: 10. This study provides beneficial information pertaining to balance and injury in this age category. With regard to the eThekwini population, representation of Africans, Indians, Whites and Coloureds should be at 71%, 19%, 8% and 2% respectively (eThekwini Municipality, 2012. Thus, in terms of the eThekwini population, the 104 ethnic distribution in this study was again not represented. This distribution could be related to participation by ethnicity in school soccer in the selected district, data for which is not available. Despite these similarities, this study contrasts with a study performed by Vignerova et al. This study included point prevalence as injury data only from the previous season were used as the current season was not completed at the time of data collection. This is supported by Lilley, Gass and Locke (2002: 4) who found that strains (35%) accounted for the highest number of injuries to female soccer players (n = 239. According to Smith (2013: 8), a strain refers to injury to the muscle as a result of overstretching, or if severe, as a result of a tear. In this study, participants self-diagnosed the type of injury which could affect the reliability of the anatomical structure which was actually injured. The participant may not have been able to differentiate between muscle injury and a cartilaginous injury for example. The most common parts of the body that were injured included the ankle and knee (Figure 4. This is supported by Mandelbaum and Putukian (1999), Boden, Griffin and Garrett Jr (2000), Ford et al. Mandelbaum and Putukian (1999: 259) and Boden, Griffin and Garrett Jr (2000: 2) indicated that knee injuries especially to the anterior cruciate ligament are significantly more common in females than in males. Muscle injuries and bruising are consistent with the results displayed in Figure 4. In this study the most common single mechanism of injury was running, followed by a collision with a player and the tackle (tackling 106 or being tackled. Despite the variability in these three mentioned studies, the three aforementioned mechanisms of injury including running, collision with a player and tackling or being tackled were more common in this particular study. According to Lephart, Pincivero and Rozzi (1998: 150), the visual and somatosensory systems are the main contributors to balance control. In this study the participants did not fall into the ‘highly trained elite athlete’ category so this study provided a good indication of the somatosensory and visual contribution to balance. In a study performed by Sellers (1988: 489) on children, it was found that Black participants had better static balance results than participants of other ethnic groups. This study supports this notion as the majority of participants in this study were Black Africans (57.

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The orientation of the coracoclavicular ligaments is critical to controlling the rotation of the clavicle order 80 mg micardis with visa blood pressure terms, enabling full elevation of the arm cheap micardis 20mg without a prescription blood pressure medication for elderly. This dual pattern of ber orientation is particularly signicant in that it is also the feature that makes a “simple surgical procedure” unlikely and unsuccessful buy 40 mg micardis heart attack fever. This position reduces the gravitational pull of the weight of the arm inferiorly and also provides some stabilization of the arm next to the trunk order micardis 80mg otc arrhythmia palpitations. Patients sometimes receive x-ray examinations in both loaded (weighted) and unloaded patterns to determine the level of clavicle displacement. The key to this technique is that the weight must be freely suspended from the arm, using no muscular action to hold it in space. The usual (normal) anteroposterior view superimposes the joint space onto the spine of the scapula. To correct for this, Zanca recommends a 10 to 15-degree superior angulation view. Ice is recommended for pain modulation and the patient may return to activity as comfortably tolerated. If activity exposes the patient to contact or impact forces, a donut pad placed over the shoulder helps to protect the joint. If used during an athletic event, the thermoplastic surface is covered with temper-foam to protect others. An exercise program designed to t the patient’s needs generally includes functional progression. If the shoulder is exposed to impact forces, the donut pad should be used as the patient returns to function. Surgeons generally attempt to pull or stabilize the clavicle downward, often to the coracoid, via a metal screw, Dacron tape, wire, or pins. Complications of such procedures can include infection, pin breakage, pin/wire migration, and resection of the clavicle or coracoid as the wire cuts through the bone. Early postoperative management often includes 4 to 6 weeks of immobilization after surgical intervention and a rehabilitation program thereafter. Functional outcomes following this procedure appear to be quite similar to those obtained through nonsurgical management. Hence current treatment is more often directed toward conservative, nonsurgical management. Also because of associated vertical instability, a residual step deformity remains at the distal clavicle, even after healing is complete. Fortunately, this deformity rarely becomes a disability, and functional outcomes are equal in patients managed with or without surgery. Because disability is most likely a problem in patients who regularly expose the arm to high-intensity demands, surgeons may consider surgical treatment under such conditions. Although the stated treatment is reduction, in reality the arm is immobilized or supported in a sling, but true reduction is not maintained. Devices have been designed to pull the humerus superiorly and the clavicle inferiorly, but their success is minimal because they are frequently associated with a lack of patient compliance. The most commonly used device is the Kenny-Howard harness, which incorporates this combination. In reality, the outcomes of treatment with a harness or benign neglect are quite similar. If you place a donut pad under one side, it is important also to pad the uninjured side to avoid alteration of shoulder pad alignment. Shoulder pads work via a cantilever design that enables forces to be placed onto the anterior and posterior thorax rather than the underlying area. A good rule is that the proper t of the shoulder pad is more important than its size or “model. Of interest, signicant disability is relatively rare, even with an obvious deformity. Patients experience long-term arthritis of the joint but again with limited symptoms. Although it might be helpful to do so, athletes usually hesitate to use a narrower grip during weight lifting because it decreases the maximal load that can be handled during bench press. Antiinflammatories, local ice application before and after exercise, and exercise modication can be used successfully in select patients. Other patients will not have a successful outcome because of established osteolysis of the distal clavicle. They may exhibit symptoms on follow-through (cross-arm motions) as well as during weight training with wide-grip bench press, dips, or cross-arm fly maneuvers. Interestingly, most surgeons today do not recommend surgical intervention for these patients, as the residual deformity potentially associated with nonoperative management does not seem to be a signicant problem and very limited functional differences in outcomes are seen. Rehabilitation after the procedure is directed toward pain modulation and support for the rst 10 to 14 days, followed by functional progression related to the specic needs of the patient. Mobilization exercises are usually performed from behind, using the horizontally placed thumb to move the clavicle forward. The therapist should maintain as much contact with the distal clavicle as possible to minimize the point of pressure. Anterior injuries are more common than posterior injuries; posterior dislocation is quite rare but may have serious implications.

A particular type of isolated cuboid fracture was presented in the literature by Hermel and Gershon Cohen[6] in 1953 who coined the term “nutcracker fracture” in order to describe a cuboid fracture that is caused by compression between the calcaneus proximally and the bases of the fourth and fifth metatarsals distally order micardis 80 mg fast delivery blood pressure device. This fracture is the result of forced plantar flexion of the hindfoot and midfoot against the fixed and forced abduction forefoot[2 buy micardis 40 mg with visa blood pressure reader,4-6] buy micardis 20 mg on-line hypertension treatment in pregnancy. This injury is also described as a result of equestrian-related injuries in children and adolescents where compression cuboid fractures are combined with other midfoot injuries such as avulsion and compression navicular or cuneiform fractures[7] discount 20 mg micardis overnight delivery prehypertension foods to avoid. Cuboid stress fractures are less common than fractures in other tarsal bones such as calcaneus and navicular because the cuboid is not a weight-bearing bone[8]. These fractures may occur in both toddlers[9-13] and adults[8,14-17] and may be a result of overuse affecting athletes[8,15] or military recruits[18]. Although they are successfully treated non-operatively without having adverse effects due to vague symptoms, they may initially not come to attention[5]. Cuboid fractures are not always recognized promptly due to the special anatomy of the foot and the difficulty in interpreting the radiologic findings. However, delayed identification and effective treatment of these injuries may have adverse effects on the biomechanics of the foot, such as loss of length of the lateral column resulting in forefoot abduction and also lesser metatarsals lateral subluxation, resulting in planus deformity associated with compensatory hindfoot eversion and posterior tibial tendon insufficiency[4,19]. Anatomical disorder of the bone articulations with tarsal bones of may lead to foot stiffness and painful arthritis as well as foot deformity[20]. This review analyzes the modern diagnostic and therapeutic approach of these rare though challenging fractures whose inappropriate and delayed management, according to their specific characteristics can have significant negative consequences on the mechanics and functionality of the foot, causing pain and stiffness to the injured limb with a final negative impact on a patient’s quality of life. It has a pyramidal shape with five articular surfaces that are articulated with the bases of the fourth and fifth metatarsal bones in front with the calcaneus on the back as well as with the lateral cuneiform and navicular medially (Figure 1. Hence it is the only bone of the tarsus involved both in the tarsometatarsal joint (Lisfranc complex) and in the midtarsal joint (Chopart’s joint. Its articulation with the fourth and fifth metatarsals provides mobility three times greater than the mobility of the first through third tarsometatarsal joints and has the largest contribution to the dorsiflexion and plantar flexion of the midfoot[19,23]. It also has a primary contribution to pronation and supination assisted in this function by the calcaneocuboid joint[19]. Due to its special anatomy and its position, the cuboid is the main supporting element of the rigid and static lateral column and ensures that its length is maintained. Its role is supported by a number of ligamentous, capsuloligamentous, and tendinous restraints. Although it does not participate directly in weight bearing, it receives significant forces during standing and ambulation, and its contribution is important in the mobility of the foot lateral column and the adaptation of the foot when walking on an uneven terrain[14,23]. The dorsal surface of the bone is bare, but on its plantar surface there is a groove that runs obliquely distal and medially and from which the tendon of peroneus longus passes acting as a fulcrum for the peroneus longus muscle contraction[4] (Figure 2. Gathering forces in this area during activities such as running can cause stress fractures[8]. Cuboid vascularization is ensured by the lateral plantar artery where anastomosis exists between the medial plantar artery. The satisfactory blood supply of the bone also explains the satisfactory bone consolidation following a fracture and the rare occurrence of events such as nonunion or osteonecrosis[4]. The Orthopaedic Trauma Association subdivides these fractures into three main categories[25]. Group A includes the simple extraarticular fractures, Group B includes calcaneocuboid or metatarsocuboid joint fractures, and Group C includes fractures involving both joints. This classification further subdivides the cuboid fractures from the simplest ones up to the most complex in each category according to the level and the particular anatomical position of each fracture. The fractures of each group are denoted with numbers with the most complex fractures being characterized by higher numbers. Fenton et al[19] proposed the classification of cuboid fractures into five groups. A type 1 fracture is the most common type of avulsion fracture involving the capsule of the calcaneocuboid joint. Type 2 includes stable isolated extra-articular injuries of the fracture that do not require surgical treatment because the length of the foot lateral column is maintained, and there is no intra-articular involvement. Type 3 injuries are isolated intra-articular fractures within the body of the cuboid involving the calcaneocuboid, the tarsometatarsal joint, or both of them. Type 4 fractures are associated with disruption of the midfoot as well as with tarsometatarsal injuries. Finally, type 5 fractures are high-energy crushing injuries of the cuboid that may be accompanied by disruption of the mid tarsal joint and loss of length of the lateral column alone or in combination with the medial column. These fractures are mostly treated surgically except in cases where the length of the foot lateral column is maintained. Regarding children, local swelling and antalgic limp with refusal to bear weight on the lateral side of the foot may accompany a fracture of the cuboid[11,27]. Cuboid fractures may be associated with lateral foot pain especially with push off when walking[28]. Typically there is tenderness to direct palpation of the cuboid over the lateral aspect of the midfoot (Figure 3) while the fracture can be accompanied by deformity, ecchymosis, or fracture blisters[5,22,23]. In the event that the calcaneocuboid joint is unstable, diagnostic maneuvers that control the integrity of this joint can cause pain[28]. Painful gait and mild tenderness on the lateral side of the foot may be present without swelling or evident hematoma[16]. If there is significant periosteal reaction or sclerosis in the fracture area, then a palpable mass may be present in the area of maximum tenderness.

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When swelling is present in the knee proven micardis 80 mg arteria jugular, this area bulges outward discount micardis 40mg blood pressure keeps rising, especially when the knee is flexed cheap micardis 80 mg line hypertension 3rd class medical. It also helps to prevent excessive tibial external rotation and femoral internal rotation order micardis 20mg mastercard hypertension complications. Each step at heel strike with the knee near full extension exerts tremendous force across the posterior lateral knee. The arcuate complex (posterior one third of lateral supporting structures including the lateral collateral ligament, the arcuate ligament, and the extension of the popliteus) helps to control internal rotation of the femur on the xed tibia during closed kinetic chain function (or external rotation of the tibia on the femur during open kinetic chain function. The posterior lateral bundle becomes more taut in extension, and the anterior medial bundle becomes more taut in flexion. Its femoral and tibial attachments in the central knee joint enable it to be an ideal passive decelerator of the femur. In this location it changes its function from extensor to flexor as the knee flexes at approximately 30 degrees. Once past 30 degrees, the tendon slips behind the horizontal axis of the knee, providing force for flexion. It has attachments into the linea aspera, which are very strong and help to prevent the pivot-shift. A high Q-angle (intersection formed by lines drawn from the anterior superior iliac spine to the center of the patella and from the center of the patella to the tibial tuberosity; normally 13 degrees in males and 18 degrees in females) predisposes the patella to sublux laterally. With the addition of a loose retinaculum, patella alta, and a weak or dysplastic vastus medialis obliquus muscle, the 550 the Knee patella can easily sublux in the rst 30 degrees of knee flexion. With a flattened lateral femoral condyle, the patellofemoral joint becomes unstable, even though the patella is seated in the trochlear groove. When a person decelerates, the knee is flexed and the patella should be in the trochlear groove. If patella alta is present, the patella may not be in the groove, thus increasing stress on the patellar tendon. The supercial layer or tangential zone is composed of densely packed, elongated cells that contain 60% to 80% water. It is the thinnest articular cartilage layer and has the highest collagen content arranged at right angles to adjacent bundles and parallel to the articular surface. This layer has the greatest ability to resist shear stresses and serves to modulate the passage of large molecules between synovial fluid and articular cartilage. Next is the transitional layer with its rounded, randomly oriented chondrocytes (articular cartilage producing cells. The design of this layer reflects the transition from the shearing forces of the supercial layer and the more compressive forces of the deep articular cartilage layers. It is known for vertical columns of cells that anchor the cartilage, distribute loads, and resist compression. The calcied cartilage layer contains the tidemark layer (boundary between calcied and uncalcied cartilage. The tidemark layer is composed of a thin basophilic line of decalcied articular cartilage separating hyaline cartilage from subchondral bone. Branches of the popliteal artery split and form a genicular anastomosis composed of the superior medial and lateral genicular arteries and the inferior medial and lateral genicular arteries. The cruciate ligaments also twist upon themselves during knee flexion and extension. The weight-bearing line or mechanical axis of the femur on the tibia is normally biased slightly toward the medial side of the knee, creating a 170 to 175-degree angle between the longitudinal axis of the femur and tibia, which is opened laterally. If this alignment is altered by degenerative changes, fracture, or genetic conditions, excessive stress is placed on either the medial or the lateral tibiofemoral joint compartment. Tibial varum or femoral valgus (angle greater than 170 to 175 degrees) leads to increased medial compartment stress, whereas femoral varum or tibial valgus (angle less than 170 to 175 degrees) leads to increased lateral compartment stress. Are there differences between female and male knee joint anatomy and biomechanics No particular anatomic or biomechanic knee joint characteristic is unique to either gender. However, females tend to have a wider pelvis, greater femoral anteversion, more frequent evidence Functional Anatomy of the Knee 551 of a coxa varus–genu valgus hip and knee joint alignment with lateral tibial torsion, a greater Q angle (18 degrees versus 13 degrees), more elastic capsuloligamentous tissues, a narrower femoral notch, and smaller diameter cruciate ligaments. What is the normal amount of tibial torsion and how does the physical therapist measure it clinically Tibial torsion can be measured by having the patient sit with their knees flexed to 90 degrees over the edge of an examining table. The therapist then places the thumb of one hand over the prominence of one malleolus and the index nger of the same hand over the prominence of the other malleolus. Looking directly down over the end of the distal thigh, the therapist visualizes the axes of the knee and of the ankle. These lines are not normally parallel but instead form a 12 to 18-degree angle because of lateral tibial rotation. While both menisci are prone to injury, the medial meniscus is at greater injury risk for both isolated and combined injury in the young athlete because of its adherence to the medial collateral ligament. In addition to transverse plane rotatory knee joint loads, any direct blows to the lateral aspect of the knee while the foot is planted may lead to injury at both the medial collateral ligament and the medial meniscus. Additionally, as a result of generally greater medial compartment weight-bearing loads during gait, the medial meniscus is more prone to degenerative tears as we age. The lateral meniscus is more often injured in combination with noncontact anterior cruciate ligament injury. The popliteus musculotendinous complex functions as a kinesthetic monitor and controller of anterior-posterior lateral meniscus movement—for unlocking and internally rotating the knee joint during flexion initiation, and for balance or postural control during single-leg stance. Increased popliteus activity during tibial internal rotation with concomitant transverse plane femoral and tibial rotation lends support to the theory that it withdraws and protects the lateral meniscus, prevents forward dislocation of the femur on the tibia, and provides an equilibrium adjustment function. Popliteus activation may be most essential during movements performed in midrange knee flexion, when capsuloligamentous structures are unable to function optimally.