Plantar Fasciitis

It’s morning, and the alarm clock has just told you it’s time to get out of bed. Another few minutes won’t hurt. You check your emails, social media sites, and you even ring your mom to see how the dog slept last night… basically anything to delay putting your feet on the ground and taking those first steps to get the day started. And it’s because of this pain you’ve been getting on the bottom of your heel every morning for the last few weeks. And it’s getting worse… Time to see your osteopath!

There are a few things that can cause pain on the bottom of the heel, but the most common cause is a condition named plantar fasciitis (also known as plantar fasciopathy).

 

What is plantar fasciitis?

Plantar fasciitis is an overuse condition affecting the plantar fascia. The plantar fascia is a layer of soft tissue that stretches along the bottom of the foot, from the heel bone to the metatarsal bones in the front of the foot. It helps to provide stability to the arch of the foot and is similar in make-up to a tendon (the things that attach muscle to bone). If too much stress is placed on this structure, over time the tissue can degenerate, weaken, and start to give you pain. The pain is commonly felt where the plantar fascia attaches into the heel bone.

 

Risk factors

Scientific research suggests there are a few groups of people who are more prone to developing plantar fasciitis. These include:

  • Runners
  • People who are over-weight and lead a sedentary lifestyle and/or spend long periods standing for work (e.g. a factory worker)

Important things to consider with these at-risk groups include:

  • Foot alignment and arch height: Having a very low or high arch or having excessive or not enough movement in the foot joints can lead to the development of this problem.
  • Amount of training: Increased levels of training can place greater stress on the plantar fascia more regularly.
  • Footwear: Wearing certain types of footwear when training can lead to an increased risk of plantar fasciitis (i.e. wearing athletics spikes, or the wrong footwear for your foot type).
  • Muscle strength and flexibility: Decreased strength in the muscles that control toe movement, as well as weakened and tight calf, hamstring and gluteal muscles are all associated with higher rates of plantar fasciitis.

 

Signs and symptoms

The signs and symptoms of plantar fasciitis include:

  • Pain at the bottom of the heel
  • Pain that appears as a gradual onset
  • Pain felt first thing in the morning (i.e. taking those first steps out of bed in the morning is classic!)
  • Pain that decreases with activity, but increases again afterwards (early stages)
  • Pain that increases with activity and pain felt at night (latter stages)
  • Pain felt after periods of prolonged rest during the day (i.e. being sat at your desk for 2-3 hours and then getting up again)
  • Tight calf, hamstring and gluteal muscles
  • Weak muscles that help to support the arch of the foot
  • Stiff or over-flexible foot and ankle joints

 

Diagnosis and treatment

First things first, if you have heel pain that sounds similar to the picture we have painted above, make an appointment with us now (you know what to do call us on (416) 546-4887). Once we have asked the relevant questions, performed the necessary tests, and are convinced that the issue stems from the plantar fascia, we will formulate a plan with you with short and long-term goals to reach within a set time.

 

Initial hands-on treatment will include a combination of massage, joint mobilisation and manipulation, and dry needling of the lower limb muscles with the aim of correcting any mechanical issues that are playing a role in this issue. Depending on the presentation, we may also use tape around the foot and ankle to provide support and reduce the stress being placed on the tissues. Other treatment will include advice on weight loss (if required), training regimen, footwear, and exercise prescription that helps to lengthen and strengthen tight and weak muscles. Some cases of plantar fasciitis may require a foot orthotic or in-sole to provide extra support to the foot whilst wearing shoes. This would be best recommended and assessed by our Chiropodist (foot specialist) at Beachealth.

 

Plantar fasciitis is a tricky condition to treat which may require ongoing treatment for several months. We will endeavour to get you pain-free in the shortest time possible, so we recommend following all advice to a T, which may include a reduction in the amount of training you are doing at present. When you start to hit goals and we see improvements being made, we’ll have you back up to your full training program before you can say “plantar fasciitis”.

 

Imaging?

 

People regularly ask if they need imaging for such an issue, but the majority of cases of plantar fasciitis can be diagnosed with a thorough case history and physical assessment. This is where we excel! Imaging is there for cases that do not respond to treatment and for those instances where we need to rule out a more serious problem.

If you need help with heel pain, please call us today on (416) 546-4887 to book your appointment. Let’s have you putting your best foot forward, ASAP! 👌

 

 

References
1. Thompson, JV. et al. 2014. Diagnosis and management of plantar fasciitis. Journal of American Osteopathic Association. 114 (12). Available from: https://jaoa.org/aoa/content_public/journal/jaoa/933660/900.pdf
2. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw Hill Education
3. Harvard Health Publishing. 2007. Easing the pain of plantar fasciitis. [Online]. Available from: https://www.health.harvard.edu/newsletter_article/Easing_the_pain_of_plantar_fasciitis. [Accessed 15 Jul 2020]
4. Orthoinfo. 2010. Plantar fasciitis and bone spurs. [Online]. Available from: https://orthoinfo.aaos.org/en/diseases–conditions/plantar-fasciitis-and-bone-spurs. [Accessed 15 Jul 2020]

Cosmetic Acupuncture

Facial rejuvenating acupuncture is a low to no-risk treatment for prevention or treatment of wrinkles and blemishes on the face. Treatments can also help with acne, rosacea, puffiness, sagging skin, and dark circles. A treatment consists of multiple fine needles placed in specific areas on the face and neck and complementary needles in the feet and hands. Each treatment lasts roughly 60-90 minutes. A study conducted and published in the International Journal of Clinical Acupuncture showed that of 300 test cases who received facial rejuvenation, 90% showed results after one course of treatment. The results included: improvement in skin texture and colouring, increased elasticity, reduction of wrinkles and overall rejuvenation.
For best results 1-2 treatments per week for 6-10 weeks is recommended with one touch up treatment every 3-4 months.
Matthew Pace, ND is now offering Facial Rejuvenating Acupuncture at Beachealth.

Orthotics

Do I need orthotics? What kind?

Many people come to the clinic complaining of foot pain from conditions such as bunions, hammertoes, a pinched nerve (neuroma), or heel pain (plantar fasciitis). I perform a thorough evaluation and examination, and together we review the origin, mechanics, and treatment plan for the specific problem.The patient usually asks if they need and orthotic and, if so, which type would be best.

I recommend a foot orthotic if muscles, tendons, ligaments, joints, or bones are not in an optimal functional position and are causing pain, discomfit, and fatigue. Foot orthotics can be made from different materials, and may be rigid, semirigid, semi flexible, or accommodative, depending o your diagnosis ad specific needs.

  Different types of orthotics

There are few types of foot orthotics: over-the-counter/off-the-shelf (OTC) orthotics; “kiosk-generated” orthotics; and professional custom orthotics. OTC orthotics are widely available and can be chosen based on shoe size and problem. Kiosk orthotics are based on the scan of your feet. A particular style or size of orthotics is recommended for you based on a foot  scan and the type of foot problem you are experiencing.

For custom prescription orthotics, a health professional performs a thorough health history, including an assessment of your height, weight, level of activity, and any medical conditions. A diagnosis and determination of the best materials and level of rigidity/flexibility of the orthotics is made, followed by casting mold of your feet. This mold is then used to create an orthotic specifically for you. The difference between OTC/ kiosk and custom made orthotics may be likened to the difference between over-the-counter and prescription reading glasses.

  Which type of orthotic is right for you?

A person of average weight, height, and foot type and with a generic problem such as heel pain, usually does well with OTC or kiosk orthotic. They are less expensive, however you may have to replace them more often. Someone with a specific need, or a problem such as severely flat foot, may benefit from custom prescription orthotics. These also last longer.

Another important fact is that your foot specialist will be able to educate you about proper footwear. You may be surprised to learn that many people have not had their feet professionally measured in years. As we age our foot length and width changes, and sizing may not be consistent between brands.

In my experience, certain groups of people benefit from an examination performed by foot specialist, and prescription for custom orthotics. These may include people with diabetes who have lost a feeling in their feet, people with poor circulation, and people with severe foot deformities caused by different foot misalignments and medical conditions.

Dead Butt Syndrome

If you sit at a desk all day, you may experience vague discomfort and pain where you sit. Doctors may call this lower cross syndrome, gluteal amnesia or gluteus medius tendinosis, but another term is more memorable: “dead butt” syndrome. In this syndrome, muscle tightness and weakness combine to create an imbalance. Constant sitting weakens the gluteus medius, one of the three primary muscles in the buttock. It also tightens the hip flexors.

 

The job of the gluteus medius is to stabilize your hips and pelvis. When it’s weak and can’t function properly, you may experience varying levels of hip and lower back pain when you sit and sometimes when you move. Muscle weakness can also compress, pull or pinch the nerves, leading to the numbness related to dead butt syndrome.

 

What causes ‘dead butt’ syndrome?

Not surprisingly, sitting for long periods in front of a desk or in a car is the most common cause of dead butt syndrome. The weakness is gradual, happening over time, and most patients have no idea what they did to cause the pain. But the problem also strikes those who are active. Athletes, especially avid runners who forgo cross-training and strength training, can also develop this syndrome

 

Simple exercises that help

1. Side-lying leg lifts

Repeat 15 to 20 times, in sets of three, every day:

  • Lie down on your right side.
  • Lift your left leg with your big toe pointing toward the floor, and lift.
  • Repeat on your left side, lifting your right leg.
    Once you are comfortable doing this exercise regularly, you can work with a band or an ankle weight for extra resistance.

2. Clamshell

Repeat 30 to 40 times, in sets of three, every day:

  • Lie down on your right side with both knees bent.
  • Keeping your feet touching, lift your bent left leg toward the ceiling.
  • Repeat on your left side, lifting your bent right leg toward the ceiling.

3. Hip Flexor Stretch

Hold for 30 seconds for each side, repeat twice a day.

  • Kneel down on your affected leg and stride the other one out in front. There should be a large space between both legs.
  • Add a pelvic tuck ie. tuck your tail under
  • Push your hips forward and raise one arm up above your head reaching up towards the ceiling while you push your hips forward. Make sure you keep your chest up. You should feel this stretch through the front of the hip.

Simple changes that head off pain

Making adjustments in how you work at your desk can also relieve dead butt syndrome — or prevent the problem before it develops. For example, try sitting for 40 minutes and then standing for 20 minutes. Use the standing time to talk on the phone or even better use a sit to stand desk. Variety is the take-home message.

Exercises for ageing bones

Are you in or approaching your latter years and are wondering what you can do to ensure your bones stay strong through the next period of your life? As we age it is common to begin feeling the effects of years of ‘life’ on your body. Diseases like osteoarthritis (i.e. degeneration of joints) and osteoporosis (i.e. weakening of bones) are more common in the elderly population. But just because the figures show this, it doesn’t mean these diseases will affect your ability to lead a full and active life.

 

The good news is, there is plenty you can do now to reduce the risk of bone-related problems down the line. Read ahead for a few exercises you can perform regularly to keep you and your bones in tip-top shape!

 

Weight-bearing and resistance are key

It is widely accepted that to increase bone health, we need to stress the bones of the skeleton. The best way to do this is through weight-bearing exercises (i.e. exercises performed in an upright position with our legs impacting the ground). Resistance-type exercises are also beneficial in protecting the skeleton against the effects of ageing. ‘Resistance’’  implies an exercise that is performed against a force acting on the body. A simple example would be to compare walking through your house to walking through strong head-on winds. The wind pushing against the body is the resistance aspect.

When we exercise, forces acting on our muscles help to build strength. The forces placed upon the skeleton through the muscles help to activate special bone-building cells within the bones, and these help to maintain or build strength in the bones depending on the intensity of the exercise. In order to increase bone strength, we need to regularly push our bodies beyond the intensity of simple everyday tasks, like walking.

 

Age is a factor

Now, if you’re worried, we’re going to suggest a new gym membership and intense weight lifting program, then rest easy. There are lots of things to consider, and age (as well as medical history) is a big factor when it comes to prescribing exercise. Someone who is 80 will need a different exercise regime compared to someone who is 55 when it comes to targeting bone health.

 

Exercises to try

The following are simple weight-bearing exercises you could have a go at doing:

  • Walking or jogging uphill
  • Hiking across the countryside
  • Stair climbing or step-ups
  • A friendly game of tennis, badminton or squash
  • Aerobics or dancing

You can add resistance to your exercise program by:

  • Lifting weights (always start light so as to not overload the body)
  • Exercising using cables or resistance bands (again, use light resistance to begin with)

 

Everyone has different requirements, so we suggest giving us a call on (416) 546-4887 or email me at daniel@beachealth.com so we can create an individual a program that is perfect for you.

 

References

  1. Hong, AR. and Kim, SW. 2018. Effects of resistance exercise on bone health. Endocrinology and metabolism. 33 (4). 435-444. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279907/
  2. Benedetti, MG. et al. 2018. The effectiveness of physical exercise on bone density in osteoporotic patients. BioMed research international. 2018, 4840531, 10 pages. Available from: https://www.hindawi.com/journals/bmri/2018/4840531/cta/
  3. Osteoporosis Australia. 2013. Exercise – consumer guide. [Online]. Available from: https://www.osteoporosis.org.au/sites/default/files/files/Exercise%20Fact%20Sheet%202nd%20Edition.pdf. [Accessed 06 Jun 2020]

Dorsal Scapular Nerve Entrapment

Has one of your shoulders been feeling a bit off lately? Is the neck and mid-back region around the shoulder blade feeling stiff and heavy? If this sounds like you, then you may have a problem with a nerve known as the Dorsal Scapular Nerve (DSN). This is a previously under-diagnosed cause of neck, mid-back and shoulder pain and dysfunction. With advances in technology and the development of knowledge and skills of treating practitioners, it has become apparent that this problem is much more common than originally thought.

Relevant anatomy

The neck is made up of a stack of seven bones known as vertebrae. These are numbered C1-7, where ‘C’ stands for cervical (i.e. the neck region of the spine). The vertebrae are numbered from top (near the skull) to bottom (where the neck meets the back). Between the vertebrae are little holes where nerves run through on their way to provide electrical signals to our muscles and other body parts. Between the 4th and 5th vertebrae, the C5 nerve root lives. The DSN is a little off-shoot of the C5 nerve root which runs from the neck to the back of the shoulder and mid-back.

 

The DSN provides electrical stimulation to three muscles in the neck/shoulder region, all of which attach to the shoulder blade (or ‘scapula’) at one end, and the spine at the other. On its way to these muscles, the nerve pierces through another muscle in the neck (one of the three scalene muscles if you’re really interested!).

 

Muscle function

Two of the three muscles that the DSN supplies help to move the shoulder blade inwards from its resting position, towards the spine. These are the Rhomboid Major and Rhomboid Minor muscles. The other muscle, the Levator Scapulae, as its name suggests, helps to elevate or lift the shoulder blade. The proper functioning of these muscles is important for us to be able to move our shoulder through its full range of motion. Injury or entrapment of the nerve can lead to poor muscle function and subsequently, poor shoulder movement.

 

Signs and symptoms

As previously mentioned, the nerve pierces through one of the neck muscles on its way to innervating the other three muscles. This creates a potential point of entrapment of the nerve and this can lead to signs and symptoms commonly experienced with DSN injury. People with DSN injury may present to the clinic with any or all of the following signs and symptoms:

 

  • Abnormal and/or reduced shoulder movement
  • Pain around the lower neck, upper/mid back and shoulder region
  • Winging of the shoulder blade (i.e. tilting of the blade away from the rib cage)
  • Difficulty with drawing shoulders backwards and together
  • Difficulty with raising the arm upwards to full range
  • Altered resting position of the shoulder blade on the injured side. Due to poor functioning of the rhomboid muscles, the shoulder blade may sit away from the spine compared to the non-injured side.
  • Weakness of the affected shoulder muscles
  • Stiffness in the neck / spine

 

Who does it affect?

DSN injuries are common throughout the general population. People whose occupation puts their posture in a compromising position every day and leaves them open to issues around the neck joints and muscles are particularly susceptible to this issue. It has also been seen in people who lift weights and after car accidents.

 

Treatment

Great news! We can help you get over this issue. Once we’ve been through our assessment and are happy with our diagnosis, we can get to work on you. Yes, this is a problem which primarily affects muscles that drive shoulder movement, but the root of the problem is usually down to poor function of the joints and muscles around the lower neck and upper back. Don’t be surprised if we direct quite a bit of our treatment at the spine. We will provide tight neck muscles with a soothing massage. Stiff neck and back joints will be mobilized and may be manipulated if we feel it is required.

As with most injuries, there is an exercise element to recovery. Poor movement patterns in the spine and shoulder have to be corrected and re-trained over a period of weeks to months. This is to ensure we get to the root cause of the problem and don’t just bandage over the top of it. Strength and stability exercises of the trunk and shoulder will be on your to-do list.

As previously mentioned, your occupation may be driving a lot of these issues. We may suggest changes to your work (i.e. a desk set-up assessment) and other aspects of your lifestyle to ensure you’re hitting this issue from all angles. That way we have more chance that the problem will be resolved permanently.

First and foremost, if you think you have a problem, please get in touch today on (416) 546-4887 or email to daniel@beachealth.com so we can start your journey to recovery.

 

References
1. Snell, RS. 2012. Clinical Anatomy by Regions. 9th ed. Philadelphia: Lippincott, Williams & Wilkins
2. Muir, B. 2017. Dorsal scapular nerve neuropathy: a narrative review of the literature. The Journal of the Canadian Chiropractic Association. 61 (2). 128-144. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5596970/

Pandemic Posture

It has been, and continues to be, uncertain times for many of us as the virus pandemic continues to sweep across the globe. Lockdown has meant many of us have had to batten down the hatches and re-discover what it means to be ‘at home’. We ask you the question “how is your body being affected?” Let us take you on a scan of the body, focus on some potentially problematic areas, and give you some advice to avoid any long-term issues.

Head and neck

First stop is the very top! For all of you that normally head out to the office every day, the pandemic might mean you’ve had to start working from home. Not having your usual desk set up can place a great deal of stress on the neck region. Are you now working on a laptop instead of a desktop computer? Are you sitting on the sofa instead of an adjustable chair? Close your eyes for 30 seconds and hone your thoughts in to your neck. Move it around… How does it feel? Is it tight, restricted or does your head feel heavier than usual? It could be that your new ‘desk’ set up’ is causing some strain in places it doesn’t usually. Think about the effect of having your head looking down at a laptop for 8 hours a day compared to straight up at a monitor set to the ideal height… Your poor muscles must be feeling the strain too. We recommend trying to recreate your office space as close as possible to the real thing. If you don’t have a desk at home, a dining table may be more suitable than sitting on a sofa or armchair. You also need to ensure you are moving your neck and shoulders more regularly to avoid them being in a strained position for too long. Take a break every 30 minutes and move into a different position.

Spine

Our spine sits at the core of the body, and we need good function throughout to ensure our limbs can also function with minimal effort and maximum efficiency. Are you used to an active job and now you find yourself homeschooling the children, or trying to break the day up with a bit of reading, gaming, TV or doing a crossword? Life is suddenly much more sedentary for most of us, so it’s important to avoid getting stiff. Sitting with poor spinal posture for extended periods, day after day can wreak havoc. Our spines curve ‘out in the mid-back and ‘in ’ in the lower back. If we don’t look after those curves carefully by protecting our posture from excessive strains, then we leave ourselves open to sore backs and poor functioning limbs as a result. We recommend avoiding long periods of sitting or lying down. Save it for bedtime! Try some standing spinal twists or bends (gently, of course), go for a walk around the garden, or do a session of yoga, Pilates or simple stretching through the day to mobilize your spine. If you have kids, get them to do it with you. They will enjoy a break from their school work, no doubt.

Hips

Anyone who works in a seated position knows what effect this can have on the hips. Having your hips in a ‘flexed’ or in a seated position for long periods of time can leave your hip flexor muscles tight and short. This decreases your ability to open the body out into a fully straight position, reducing flow of fluids through the central part of your body and leaving the back chain of muscles in a lengthened state, which can eventually result in the weakening of the chain. We recommend lots of upright exercises for this one. Counteract the time spent seated working or binge watching a TV series with some standing-based exercise. Jumps, skipping, walking, running or bridging is a nice way to open those hips and get the blood flowing. Our underlying message through all of this is to move, move, move! You are a movement machine, so regularly start the ignition and go for a spin. Look after yourselves and please get in touch today on 416-546-4887 if you need help keeping your pandemic posture in check!

Winging of the shoulder blades

Do you have, or have you ever seen someone whose shoulder blades stick out on their back and look a little bit like wings? This condition is aptly named ‘winging’ of the shoulder blades.

SCAPULA bone anatomy x-ray scan

Anatomy

Osteopaths love a bit of anatomy! The shoulder blade or ‘scapula’ is a largely flat bone that sits on the back of the rib cage and is an important ingredient in what makes up the various joints of the shoulder. As well as the larger flat part, a few extra lumps and bumps makes for a very odd shaped bone when looked at in isolation. One of the bony protrusions actually makes up the ‘socket’ part of the ball and socket joint in the shoulder. The ‘ball’ part being made from the head of the upper arm bone (aka the ‘humerus’).

Interesting fact… There are 18 muscle attachments on the shoulder blade. It is through fine balancing of these muscles which keeps the shoulder blade stabilized and flush to the back of rib cage and allows us to move our shoulders through an extremely large range of motion. As you can imagine, keeping all of these muscles in full working order takes a bit of co-ordination and with so many players involved, there is room for dysfunction to creep in and movement to become affected. Sometimes the dysfunction is great enough to cause the shoulder blade to flip outwards from the rib cage, and this is what we refer to as ‘winging’.

 

Causes of winging

The causes of shoulder blade winging can be broadly broken down into:

  • Muscular: As we previously mentioned, lots of muscles are responsible for controlling the position and movement of the shoulder blade. Injury to these muscles, or an imbalance in the strength, length and function of the muscles over a prolonged period may lead to this issue. The main muscles involved here are the Serratus Anterior (a muscle which attaches to the ribs and the underside of the shoulder blade), and the Trapezius (a kite shaped muscle which covers the back of the neck, shoulders and upper back… Aka ‘traps’). It’s more complex and there are more muscles involved, but these are the key players when it comes to winging.
  • Neurological: Muscles require a nerve supply in order to move, so if any of the nerves that supply the key players (i.e. Serratus and Traps) are injured, this can stop the muscles from being able to perform their job. Nerves can be injured through entrapment, where something presses on a nerve as it travels from the spine down to the muscle it supplies. Other causes may be from acute traumas as seen with car or sporting accidents where the shoulder takes a direct blow while the arm or neck are suddenly pulled.

Other ways these injuries may come about include prolonged wearing of a heavy backpack, complications following surgery, or as a result of a viral infection that affects the nerve.

 

Signs and Symptoms

The main sign is a shoulder blade that doesn’t sit snug to the rib cage, particularly when trying to move the arm upwards in front of the body or out to the side. Many people with scapula winging feel no pain whatsoever, but this can be a very painful condition if the cause is from a severe nerve injury. Another key sign is the inability of a person to lift their arm above their head.

 

Treatment

The treatment of shoulder blade winging very much depends on the cause. If the shoulder blades are winging because of a muscular imbalance, these are a little easier and faster to rehab. After careful assessment of your shoulder, neck and other spinal movements, we will aim to restore full functioning of the muscles that control the position and movement of the shoulder blades. This might include techniques which aim to lengthen short or tight muscles which are pulling the shoulder blade out of position. If there is a weakness to a particular muscle or group of muscles, we will also prescribe you strengthening and movement re-training exercises which aim to return the shoulder blade to its functional position.

Winging caused from nerve entrapment or injury is notoriously harder to treat. If entrapment of the nerve is caused by muscular tension in another part of the body, or because you’ve been carrying a heavy backpack for too long, then we will work on the relevant muscles and nerves to release the entrapment and pressure. We might also need to adjust how you wear your backpack and how much weight is inside while we focus on improving your physical impairments. Nerve-related injuries can take much longer to resolve. Winging caused by paralysis of the nerve which supplies the Serratus Anterior muscle has been known to take up to two years to resolve. The good news is, most people will make a full recovery in this time with surgical procedures saved only for more complex or unresolved cases. Which if you ask any Osteo, is always the goal!

If you notice winging of the shoulder blades, or difficulty with achieving full shoulder range of motion, then get in touch today on 416-546-4887. We would love to chat to you about your issue in a phone or video consult and get you on the road to recovery as soon as possible.

 

References

  1. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw Hill Education
  2. Snell, R. 2012. Clinical Anatomy by Regions. 9th ed. USA: Lippincott Williams & Wilkins
  3. Magee, D. 2008. Orthopaedic Physical Assessment. 5th ed. USA: Saunders Elsevier