Musculoskeletal and Soft Tissue Disorders - Mayo … and... · Musculoskeletal and Soft Tissue...

Musculoskeletal and Soft Tissue Disorders

• Brian Grogg, MD is a Consultant in the Department of Physical Medicine and Rehabilitation at the Mayo Clinic in Rochester, MN

• Dr. Grogg is an Assistant Professor in the College of Medicine

• He is board certified in PM&R • Clinical interests include utilizing ultrasound in

musculoskeletal medicine

Mayo Clinic Physical Medicine and Rehabilitation Board Review

Musculoskeletal and Soft Tissue Disorders Online Curriculum Brian Grogg, MD

Physical Medicine and Rehabilitation Board Review

Disclosures • Financial-None • Off Label Use-None

Objectives • Identify common musculoskeletal disorders • Know the management options for common

musculoskeletal disorders

Outline • Spine • Upper Extremity • Lower Extremity • Myofascial Pain • Arthroplasty Rehabilitation

Spine Disorders-General Principles • Anatomy

Spine Disorders-General Principles

Spine Disorders-General Principles • Red Flags

• gait disorder • weakness • bowel/bladder changes • night pain • unintentional weight loss • fever/chills • night sweats

Cuccurullo, S. 2004

Spine Disorders-General Principles • “Yellow Flags”—indicators of potential disability

• Fear-avoidance behavior • Medico-legal issues • Waddell’s (TORDS) • Mood disorder • History of abuse • Work-related disability—unhappy with

supervisor or job, missed time from work

Spine Disorders-Cervical Radiculopathy • Pain radiating from the neck into upper limb or

medial scapula region • Paresthesias and/or weakness • C6, C7 • Etiology: disc herniation, degenerative changes

resulting in foraminal narrowing • Management: medications, physical therapy,

epidural corticosteroid injections, surgery

Radharkrishnan, 1994

Spine Disorders-Cervical Stenosis

• Most common cervical cord lesion after middle age (Wilkinson, 1960)

• Degenerative changes narrow the spinal canal diameter (> 1/3) (Penning, 1986)

• Insidious weakness (LE>UE), gait disorder, bowel/bladder changes, may have UE radicular symptoms

• UMN findings on exam • Treatment: monitor/education, maximize

balance, surgery

Spine Disorders- Cervical Facet Syndrome • Facet joints are true

synovial joints

• Pain from arthritis, injury

• Clinical: primarily axial pain, exacerbated by extension, tenderness, decreased ROM

• (Cooper, 2007)

Spine Disorders-Cervical Facet Syndrome • Imaging: degenerative changes, MRI with

periarticular edema or fluid within joint • Treatment:

• Medications • Manual medicine • Exercise program to promote proper posture • Injections • MBB/RFA

Spine Disorders-Scheuermann’s Kyphosis • Progressive thoracic kyphosis in adolescents • Disorder of vertebral endplates and apophysis • Kyphosis is fixed on exam • X-rays: Schmorl’s nodes and anterior wedging

of vertebral bodies • Treatment: spine stabilization, symptom

management • (Brown, 2004)

Spine Disorders-Vertebral Body Fractures • Compression fractures, typically thoracic

• Etiology: osteoporosis, trauma, neoplasm

• Severe localized pain, often sudden

• Focal tenderness on exam

• X-ray: vertebral body compression

• MRI: vertebral body compression +/- edema

• Treatment: pain medications, bracing, hyperextension exercises, vertebroplasty/kyphoplasty, rarely surgery

• (Brown, 2004)

Spine Disorders-Lumbar Facet Syndrome • Facet joints are true synovial joints • Pain from arthritis, injury • Clinical: primarily axial pain, exacerbated by

extension, tenderness, decreased ROM • Referral patterns vary

Spine Disorders-Lumbar Facet Syndrome • Imaging: degenerative changes, MRI with

periarticular edema or fluid within joint • Treatment:

• Medications • manual medicine • lumbar stabilization program • Injections • MBB/RFA

Spine Disorders-Lumbar Disc Disorders • Discogenic Pain: internal disc disruption, disc

degeneration

• Lumbosacral pain, may radiate to buttock or proximal LE

• Exacerbated by increasing disc pressure • sitting • cough/strain/sneeze • flexion

• Treatment: medications, lumbar stabilization, epidural?

• Controversial treatments: disc replacement, lumbar fusion, IDET

Spine Disorders-Lumbar Radiculopathy • Nerve root pain related to the lumbar spine • Mechanical compression or chemical irritation • Rare causes: infection, malignancy, fracture • L5 and S1 radiculopathies most common • Treatments: time, medications, relative rest,

exercise, epidural corticosteroid injections, surgery

• (Vad, 2002)

Spine Disorders-Lumbar Stenosis • Central canal narrowing + neurologic symptoms • Neurogenic claudication: Lower extremity pain,

paresthesias, and/or weakness with standing/walking/extension

• Majority remain stable (Johnsson, 1992)

• Neurologic decline rare, no harm waiting for surgery (Amundson, 2000)

• Treatments: walker w/ seat, medications, ESI, surgery Mayo Clinic Physical Medicine and Rehabilitation Board Review

Spine Disorders-Cauda Equina Syndrome • Rare condition affecting the nerve roots of the

cauda equina • Usually due to large disc herniation • Less likely caused by trauma, infection, tumor,

hematoma • Saddle anesthesia, bowel/bladder dysfunction,

LE pain/paresthesias/weakness • Treatment: Emergent surgery

Spine Disorders-Sacroiliac Joint Pain • Low back, buttock, or LE pain • No consistent history or exam findings • Etiology: degenerative, traumatic, hypermobile,

hypomobile, pregnancy, spondyloarthropathy • Treatment: Manual medicine, medications,

physical therapy, injections • Surgery is controversial

Spine Disorders-Infections • Osteomyelitis, discitis, epidural space, facet joint

• Typically presents with insidious back pain

• Risks: immunocompromised, IV drug use, DM, hemodialysis

• “Rule of 50” (Tali, 2004) • >50 y/o • 50% have nl WBC, fever, sx > 3 months • 50% lumbar • 50% originate in urinary tract

• Treatments: IV antibiotics 4-6 weeks

Shoulder Disorders-Glenohumeral Joint Osteoarthritis • Painful and reduced ROM • Risks: prior dislocations, trauma, fractures • ROM globally reduced and pain with movement

in all directions • Diagnosis: imaging and clinical • Treatments: medications, injections, TSA,

reverse arthroplasty with RTC deficiency

Shoulder Disorders-Rotator Cuff Disorders • Supraspinatus • Infraspinatus • Teres minor • Subscapularis

Shoulder Disorders-Rotator Cuff Disorders • Tendinopathy, SA/SD bursopathy, partial tendon

tears, complete tears, calcific tendonitis

• Etiology: trauma, repetitive microtrauma, external impingement, internal impingement

Shoulder Disorders-Rotator Cuff Disorders • Acromion Types

• Type I: flat • Type II: curved • Type III: hooked

• Risk of RTC tendon tears increases from I-III

• (Bigliani, 1986)

Shoulder Disorders-Rotator Cuff Disorders • Anterolateral shoulder pain at night, with

abduction, internal rotation, overhead activities • PE: painful arc, Hawkin’s, Neer’s, Drop Arm

Test • Xrays, MRI • Treatments: medications, activity modifications,

subacromial corticosteroid injection, physical therapy, surgery

• Acute, full-thickness tears should receive surgery consult

Shoulder Disorders-Adhesive Capsulitis • “Frozen Shoulder”

• Painful restriction of shoulder ROM, fibrocartilaginous proliferation

• Decreased internal/external rotation on exam

• 2-5% of general population

• 2-4 x more likely in females

• DM

• 40-60 y/o

(Bunker 1995, Connolly 1998)

Shoulder Disorders-Adhesive Capsulitis • Four Stages

• I: 1-3 months, painful movement but minimally restricted

• II: 3-9 months, painful movement with loss of motion

• III: 9-15 months, reduced pain but severely limited motion

• IV: 15-24 months, minimal pain and gradual improvement in ROM

• (Hannafin 2000)

Shoulder Disorders-Adhesive Capsulitis • Treatment:

• Medications • Intraarticular Corticosteroid Injection • AAROM • Surgery

• Manipulation under anesthesia • Arthroscopic capsular release • Open release

Elbow Disorders-Olecranon Bursopathy • Swollen olecranon bursa • Etiology: trauma, inflammatory disorder • Redness, warmth may suggest infection • Treatment: protection, ice, aspiration to r/o

infection if clinically indicated

Elbow Disorders-Osteoarthritis • Painful, decreased ROM • H/o trauma • Osteoarthritis on xray • Treatment:

• Physical therapy • Medication • Injections • Surgical referral

Hand and Wrist Disorders-Ganglion Cysts • Cystic structure arising from synovium • Often painless • Dorsum of the wrist, “snuff box” • Treatment:

• monitor • aspiration (recurrence common) • surgical resection

Hand and Wrist Disorders-DeQuervain’s Tenosynovitis • Stenosing tenosynovitis of the first dorsal

compartment (APL, EPB) • Most common tenosynovitis of the wrist • Repetitive gripping • Tenderness to palpation, edema, Finkelstein’s

test • (Conklin et al, 1960)

Hand and Wrist Disorders-DeQuervain’s Tenosynovitis • Finkelstein’s test

Hand and Wrist Disorders-DeQuervain’s Tenosynovitis • Treatment: activity modification, ice, NSAIDS,

physical therapy, corticosteroid injection • Injections 62-100% improved

• (Wood, 1986)

Hand and Wrist Disorders-Osteonecrosis of the Lunate • Kienbock disease

• Vascular compromise of the lunate progressing to avascular necrosis

• Pain and stiffness • Diagnose:

• X-ray—scleroiscollapse • Bone scan, MRI

• Treatment: immoblization early, surgical referral

• (Stahl, 1947)

Hand and Wrist Disorders-Stenosing Tenosynovitis • “Trigger Finger” • Catching/locking of the finger in flexion • Repetitive trauma, DM, inflammatory arthritis • Nodule forms on flexor tendonnodule passes

under A1 pulley upon flexioncaught upon extensionfinger locked in flexion

• Treatment: corticosteroid injection, surgery

Hand and Wrist Disorders-Carpal Tunnel Syndrome DoPhotoShop/Wikimedia Commons

Hand and Wrist Disorders-Carpal Tunnel Syndrome • Pain • Paresthesias in median innervated digits • Associations: pregnancy, DM, inflammatory

arthritis • Symptoms worse at night, wrist flexion • PE: Tinel’s, Phalen’s, Carpal Compression,

weakness/atrophy in advanced cases

Hand and Wrist Disorders-Carpal Tunnel Syndrome • Diagnose: Clinically, EMG, US

• Treatment: wrist splints, corticosteroid injection,

surgery

Hand and Wrist Disorders-Osteoarthritis • 1st CMC joint

• Common • Female • Pain, stiffness, tenderness • Diagnose: xray • Treatment: NSAIDs, acetaminophen, thumb

spica, corticosteroid injection, surgical referral

• (Peter, 1968)

Hip Disorders-General Principles • Location

• Buttock, groin, anterior thigh

• Gait • Compensated Trendelenburg

• Aggravators • Crossing legs

Hip Disorders-Trochanteric Pain Syndrome • Gluteus medius syndrome, Trochanteric bursitis • History:

• Pain in lateral thigh with hip flexion and lying on the affected side

• Location: greater trochanter, ITB • Causes: trauma, weakness, pes planus

Hip Disorders-Trochanteric Pain Syndrome • Physical Examination

• Tenderness to palpation • Pain with ER>IR of the hip • Tight ITB • Pain associated weakness; compensated

trendelenburg • Pes planus

Hip Disorders-Trochanteric Pain Syndrome • Management

• US • Stretch ITB • Ice • Arch supports • Cane • NSAIDS • Injection

Hip Disorders-Avascular Necrosis of the Femoral Head • 15000-20000 new cases in U.S. per year • 10% of THA • 40-60% bilateral • Late 30s to 50s • Not likely in the elderly due to marrow changes-

--gelatinous marrow • (Lavernia, 1999)

Hip Disorders-Avascular Necrosis of the Femoral Head

• Hemodialysis • Gaucher disease • Hemophilia • Hemoglobinopathies • Hypercoaguable state • Collagen vascular

disease/SLE • Smoking • Pregnancy

• (Mont, 1995)

• Etiology: • Trauma • Alcoholism • Corticosteroid • Caisson Disease • Pancreatic Disease • Radiation • Dialysis • Hyperlipidemia

Hip Disorders-Avascular Necrosis of the Femoral Head • Radiography

• Femoral head lucency, subchondral sclerosis

• Subchondral collapse (crescent sign), femoral head flattening

• Femoral head collapse, joint space narrowing

• MRI • Most sensitive, most

specific • Diffuse edema early (low

T1, high T2) • Edema becomes more

focal • Serpiginous line of low

signal intensity • SE T2: peripheral band of

low signal, inner aspect of band with high signal; “double-line sign”

Hip Disorders-Avascular Necrosis of the Femoral Head • Management

• Non-weight bearing • Core decompression

• Bone grafting • Vascularized fibular graft

• Resurfacing, bipolar arthroplasty • Total Hip Arthroplasty

Hip Disorders-Osteoarthritis History • pain in groin, buttock, lateral thigh and/or

anterior thigh • pain worse with weight bearing and rotation

(crossing legs, donning/doffing shoes)

• <15 minute stiffness after immobilization • Risks: age, trauma, developmental

abnormalities, repetitive heavy lifting/farming, obesity Mayo Clinic Physical Medicine and Rehabilitation Board Review

Hip Disorders-Osteoarthritis • Physical Examination

• Compensated Trendelenburg gait

• Pain reproduced with IR>ER

• Positive Stinchfield and FABER

• Reduced ROM • Weak hip abductors

• Imaging • Osteophytes • Subchondral sclerosis • Subchondral cysts • Intra-articular loose

bodies

Hip Disorders-Osteoarthritis • Management:

• Education • Cane • Medications • Physical therapy • Injection

• Corticosteroid • Decrease pain, stiffness, and impairment up to 3

months • Viscosupplementation

• Studies suggest variable, modest outcomes • Surgery

Hip Disorders-Fractures • History

• Repetitive stress/overuse

• Osteoporosis • Groin and or thigh pain

with weight bearing

• Physical Examination • Hip joint provocative

tests positive • Fulcrum test • Pound test

Hip Disorders-Fractures • Compression type

• Most common • Inferior neck of femur • Can treat with non-

weightbearing (4-6 weeks) and progress weightbearing as tolerated

• Tension Type • Superior neck of femur • Treated with internal

fixation

Hip Disorders-Piriformis Syndrome • History

• Buttock and/or posterior thigh pain

• +/- paresthesias • Symptoms usually

worse with sitting; +/- walking and standing

• Physical Examination • Palpatory tenderness

over the piriformis, sciatic notch

• Pain with stretching

• Imaging

Hip Disorders-Piriformis Syndrome • Management

• Stretch piriformis • US • Myofascial release • Manual medicine • Injections

• Corticosteroid • Botulinum toxin

Knee Disorders-Patellofemoral Pain • History

• Anterior knee pain • Squatting, kneeling

• Physical Exam • Patellofemoral grind • patella alta, tight ITB,

increased Q angle

• Risk Factors: female, tight lateral retinaculum, VMO dysfunction, hip abductor weakness

Knee Disorders-Patellofemoral pain • Treatment:

• Medications • Taping • Bracing • Strengthen VMO and hip abductors • Stretch ITB, hip adductors, hamstring

Knee Disorders-Patellofemoral Pain • Chondromalacia patella

• Cartilage damage • Longstanding mal-tracking? Trauma? • Treatment:

• patellofemoral pain plus: • corticosteroid injections • viscosupplementation

Knee Disorders-Osteoarthritis • History

• Pain • Swelling • Stiffness • Exacerbated by weight

bearing and after prolonged immobilization

• Exam • Joint line tenderness • Effusion • Pseudo-laxity • Varus/valgus

deformities

Knee Disorders-Osteoarthritis • Risk Factor

• Age • Weight • Female gender • Trauma • Infection • Genetic • Metabolic disorders

• Ex. Hemosiderosis, acromegaly

Knee Disorders-Osteoarthritis • Treatment

• Weight loss • Exercise • Acetaminophen • NSAIDs • Capsaicin • Glucosamine • Injections

• Corticosteroid, viscosupplementation, PRP, stem cells

• Surgery Mayo Clinic Physical Medicine and Rehabilitation Board Review

Foot and Ankle Disorders-Plantar Fasciitis • History

• Medial plantar heel pain

• Morning • After immobilization

• Exam • Tenderness-medial

plantar calcaneous • Pain with plantar fascia

stretching • Pes planus? • Pes cavus? • Tight GS complex?

Foot and Ankle Disorders-Plantar Fasciitis • Treatment

• Ice • NSAIDS • Modalities • Orthotic • Stretch GS complex and plantar fascia • Night splint • Injection • Surgery

Foot and Ankle Disorders-Osteoarthritis • Tibiotalar, subtalar, midfoot, forefoot • Pain, swelling, tenderness • Risks: trauma • Diagnose: clinically, x-ray • Treatment: acetaminophen, NSAIDS, bracing,

injections, surgery

Foot and Ankle Disorders-Morton’s Neuroma • Interdigital nerve irritation in the foot

• Most common—between 3rd-4th MT

• Insidious pain in MT head region

• Paresthesias

• Exam: tenderness, “click”

• Treatment: • unload the forefoot • distribute forces via orthotics • shoes with wide toe box • injection • surgery (Fitzgibbons, 1996)

Myofascial Pain • Localized vs Diffuse • Diffuse, muscular pain, and tenderness

• Trigger Points • Fibromyalgia • Central Sensitization Syndrome

Myofascial Pain • Fibromyalgia

• 2-4% of population • 80-90% female • Diagnostic criteria, modified ACR 2010

• 19 painful/tender areas in the last week plus a patient reported score for—difficulty sleeping, fatigue, poor cognition, headaches, abdominal pain, depression

• > 3 months duration • No other explanation for symptoms

• (Bennett, 2014)

Myofascial Pain • Fibromyalgia

• Treatment • Behavioral • Exercise • Tai Chi • Yoga • Antidepressants • Acupuncture • Gabapentin • Pregabalin • Duloxetine

Myofascial Pain • Central Sensitization Syndrome

• Appears to play role in FM and other chronic pain syndromes

• Repeated noxious stimuli in the dorsal horn of spinal cord sensitization or increased responsiveness hyperalgesia & allodynia

• Altered function of pain inhibitory/facilitory centers in the brainstem

• (Staud R, 2002 and Eriksen, 2004)

Joint Arthroplasty Rehabilitation • Knee

• Rehabilitation protocols vary • Rehabilitation Effectiveness

• Improves early function and ROM • Does not improve early QOL or walking • No difference in therapy vs no-therapy for

any category at one year • (Minns Lowe, 2007)

• Complications • Thromboembolic

• 2.1% • (White, 1998)

• Aseptic loosening • Knee stiffness • Neurologic injury (7.7%)

• peroneal, tibial • longer tourniquet time

• (Horlocker, 2006)

• Long term exercise • Recommended: cycling, golfing, swimming,

walking, hiking, bowling • Allowed with experience: low-impact aerobics,

horseback riding, cross-country skiing, doubles tennis

• Not recommended: basketball, jogging, soccer, volleyball

• (Healey, 2008)

Joint Arthroplasty Rehabilitation • Hip

• Rehabilitation protocols vary • Complications

• Dislocation 3-10% • Avoid flexion, adduction, IR

• Infection 0.2% • Thromboembolic • Nerve injury 0-3%

• Peroneal division of sciatic • Leg-length discrepancy

• Most often functional and resolves • (Barrack, 2004) (Soong, 2004)

Joint Arthroplasty Rehabilitation • Hip

• Long term exercise • Hip group musculature weaker on involved side

• Recommended: cycling, golfing, swimming, walking, hiking, bowling

• Allowed with experience: low-impact aerobics, horseback riding, cross-country skiing, downhill skiing, doubles tennis

• Not recommended: basketball, jogging, soccer, volleyball

• (Healey, 2008)

References • Amundson T, Weber H, Nordal HJ, et al. Lumbar spinal stenosis:

conservative or surgical management? A prospective 10 year study. Spine 2000; 25(11):1424-35.

• Barrack RL. Neurovascular injury: avoiding catastrophe. J Arthroplasty 2004; 19(Supp 1):104-107.

• Bennett RM, Friend R, Marcus D, et al. Criteria for the diagnosis of fibromyalgia: validation of the modified 2010 preliminary American College of Rheumatology criteria and the development of alternative criteria. Arthritis Care Res 2014; 66(9):1364-73.

• Bigliani L, Morrison DS, April EW. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 1986;10:228.

• Brown DP, Freeman ED, Cuccurullo S. Musculoskeletal Medicine in Cucurrullo S ed. Physical Medicine and Rehabilitation Board Review. Demos Medical Publishing NY, NY 2004, pg 284-5.

References • Bunker R, Anthony PP. The pathology of frozen shoulder: a

Dupuytren-like disease. JBJS Br 1995;77:677-683.

• Conklin J, White W. Stenosing tenosynovitis and its possible relation to the carpal tunnel syndrome. Surg Clin N Am 1960; 40:531-40.

• Connolly J. Unfreezing the frozen shoulder. J Musculoskel Med 1998;Nov:47-58.

• Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Medicine 2007;8(4):344-53.

• Della-Giustina DA. Emergency department evaluation and treatment of back pain. Emerg Med Clin N Am. 1999; 17(4):vi-vii, 877-93.

References • Eiff M, Hatch RL, Calmbach WL. Carpal fractures. In Eiff M, Hatch

RL, Calmbach WL, eds. Fracture management for primary care. Philadelphia: Saunders; 1998:65-77.

• Eriksen HR, Ursin H. Subjective health complaints, sensitization, and sustained cognitive activation. J. Psychosom Res 2004;56:445-8.

• Fitzgibbons T, Keown B, Sampson C, et al. Foot Problems in Athletes. In: Mellion M ed. Office Sports Medicine 2nd Ed. Philadelphia: Hanley and Belfus; 1996:318-36.

• Hannafin J, Chiaia TA. Adhesive capsulitis. Clin Orthop 2000; 372:95-109.

• Healey WL, et al. Athletic activity after total joint arthroplasty. JBJS 2008; 90:2245-52.

References • Horlocker TT, et al. Anesthetic, patient, and surgical risk factors for

neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesthesia & Analgesia. March 2006; 102(3):950-55.

• Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop 1992; Jun(279):82-6.

• Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J of the Am Acad Orthop Surg 1999; 7(4):250-61.

• Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of phsyiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ 2007; 335:812.

• Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. JBJS Am 1995; 77(3):459-74.

References • Penning L, Wilmink JT, Van Woerden HH, et al. CT myelographic

findings in degenerative disorders of the cervical spine: clinical significance. AJR 1986; 7:119-27.

• Peter JB, Marmor L. Osteoarthritis of the first carpometacarpal joint. California Medicine 1968; 109(2): 116-20.

• Radharkrishnan K, et al. Epidemiology of Cervical Radiculopathy. A population-based study from Rochester, MN 1976-1990. Brain 1994; 117(pt 2):325-335.

• Soong M, Rubash HE, Macualy W. Dislocation after total hip arthroplasty. J Am Acad Orthop Surg 2004; 12(15):314-21.

• Stahl F. On lunatomalacia (Kienbock’s disease), a clinical and roentgenological study, especially on its pathogenesis and the late results of immobilization treatment. Acta Chir Scand (Suppl) 1947; 126:1-133.

References • Staud R, Simtherman ML. Peripheral and central sensitization in

FM: pathogenic role. Curr Pain Headache Rep 2002; 6:259-66.

• Tali ET. Spinal Infections. Eur J Rad 2004; 50(2):120-33.

• Vad VB, Bhat AL, Lutz GE, et al. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine 2002; 27(1):11-16.

• Wilkinson M. The morbid anatomy of cervical spondylosis and myelopathy. Brain 1960; 83:589-616.

• Wood M, Dobyns J. Sports-related articular wrist syndromes. Clin Orthop 1986; 262:93-102.

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