Tendon, Muscle, and Cartilage Injuries


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Recap biomechanics of soft tissue injury
Value of exercise as treatment tool
Tendon pathologies and treatment options
Chronic tendinopathy
Acute rupture
Traumatic Muscle Injuries
Hamstring Injury, Micheal Owen
Meniscal Injuries

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  • Biomechanics CT composition – structure function
  • Some studies which show Physiotherapy is ineffective. Do not subgroup subjects so it is very important to critically appraise articles. To demonstrate that it does matter which tool is use we are going to work through an example of how research and its clinical application have made exciting advances in the treatment of TA problems
  • Note the word tendinopathy not tendonitis
  • Used to think TA problems were due to inflammation but…. Old treatment is massage and US stretch ice
  • 15 patients who had tried all non-surgical treatment-no effect Couldn’t run. Weak concentric and eccentric muscle strength Control group: 15 other patients received conventional therapy (NSAID, stretching, concentric, ice etc)-no one better-all had surgery. Treatment group: All 15 got full strength and could return to running Could the previous study be reproduced? 2003: Mid portion achilles pain: 101 tendons 89% good results Instertional pain: 31 tendons 32% good results eccentric exercises twice daily, 7 days/week, for 12 weeks. The calf-muscle was eccentrically loaded both with the knee straight and—to maximize the activation of the soleus muscle—also with the knee bent. Each of the two exercises (3×15 reps). In the beginning the loading patients were standing with all their body weight on their injured leg.. They were only loading the calf-muscle eccentrically, no following concentric loading was done. Instead, the noninjured leg was used to get back to the start position. The patients were told that the exercises should be painful , and when there was no pain in the tendon during training the load should be elevated to reach a new level of painful training . Increasing the load could easily be done by using a backpack that was successively loaded with weight. If very high weights were needed, the patients where told to use a weight-machine.
  • Patient suffering from chronic Achilles tendinosis Nerve bundle (N) in the proximity of Blood vessel (asterisk in lumen) . Nerve fibre (arrow) close to the vessel wall
  • It is probably important to strengthen the tendons with eccentric training to prevent re injury. Ultrasound and colour Doppler examination of a patient with chronic painful mid-portion Achilles tendinosis. a Resting position -no dorsiflexion in the ankle joint. Longitudinal view, showing a thickening of the tendon, structural abnormalities with hypoechoic areas, and neovascularisation ( coloured structures ) inside and outside the ventral part of the tendon. b During dorsiflexion in the ankle joint. Longitudinal view, showing a thickening of the tendon, structural abnormalities with hypoechoic areas, but no flow in the neovessels
  • Before treatment, there was a local neovascularisation in the area with tendon changes in all tendons. At follow-up after treatment (mean 28 months), there was a good clinical result (no tendon pain during activity) in 36/41 tendons, and a poor result in 5/41 tendons. In 34/36 tendons with a good clinical result of treatment there was a more normal tendon structure, and in 32/36 tendons there was no remaining neovascularisation. In 5/5 tendons with a poor clinical result there was a remaining neovascularisation in the tendon, and in 2/5 tendons there were remaining structural abnormalities. In conclusion, in patients with chronic painful mid-portion Achilles tendinosis, a good clinical result after eccentric training seems to be associated with a more normal tendon structure and no remaining neovascularisation. Action in the area with neovessels during the eccentric training regimen might possibly be responsible for the good clinical results.
  • Summary of TA tendiopathy Neovessels and structural changes were found in Achilles tendons with painful tendinosis but not in normal tendons The flow in the neovessels disappeared in ankle dorsiflexion and no neovessels were found after eccentric training in pain free patients Tissue can be remodelled by eccentric training
  • Mechanism of Injury
  • Treatment options?
  • Pain Weigthbearing Odema Deformity Loss of function Feels a thump
  • Rehab?
  • Grade I Microscopic injury to muscle tissue due excess stretching Localised pain Grade II Rupture of several muscle fibres and local bleeding Intense pain with sudden onset Active movement painful Grade III Total muscle rupture, audible pop followed by intense and severe pain Muscle mobility often diminished or absent
  • A contusion is a bump that happens under the skin after an injury. This bump is caused when fluid collects under the skin. A haematoma is also a bump that happens under the skin after an injury. But this bump is caused by blood that collects under the skin. Each can be called a bruise. The closer the broken blood vessels are to the surface, the sooner the bruise appears and the more intense its colours will be.
  • Bruises may last longer in elderly people, because restricted circulation slows the removal of the decaying blood components Rehab?
  • Contraction of hamstrings extends the hip and flexes the knee During sprinting the thigh moves upwards and forwards due to the contraction of the hip flexors If the hamstrings do not relax they will be forced to lengthen even if fibres are still contracted = muscle strain or tear However they still need some tension within them to control the extension of the knee (eccentric lengthening) Two main causes; Sprinting (load vs deformation) Extreme slow stretching (creep)
  • Most of these injuries occur when athletes don't warm up properly. Football stars such as Michael Owen don't run on maximum velocity, but when they do go up that extra gear, that's when the trouble begins You need a strong and flexible hamstring. To achieve this involves a lot of stretching and weight training. It is essential that the muscle is warmed up and stretched before taking part in vigorous exercise. Return to sport 2-4 weeks if strained up to eight weeks if a tear Surgery not appropriate PRICE (no heat) NSAIDS
  • Owen came on as a substitute - it is likely that he may not have done enough stretching before he came on, or he may have picked up the injury in warm-up. Rt knee ACL. Rt knee Ham
  • Rehab?
  • Cyst formation (fluid left from a haematoma) Infection Muscle shortening (scaring/ poor rehab) Scaring Muscle fibres are replaced by collagenous scar tissue Scar tissue will contract Loss of flexibility Causes ongoing discomfort and pain Scar tissue has less tensile strength = recurrent injury What is Myositis Ossificans? If you have a bad muscle strain or contusion (dead leg!) and it is neglected then you could be unlucky enough to get Myositis Ossificans. It is usually as a result of impact which causes damage to the sheath that surrounds a bone (periostium) as well as to the muscle. Bone will grow within the muscle (called calcification) which is painful. The bone will grow 2 to 4 weeks after the injury and be mature bone within 3 to 6 months. What causes myositis ossificans? Not applying R.I.C.E. (rest, ice, compression and elevation) immediately after the injury. Having intensive physiotherapy or massage too soon after the injury. Use someone who is properly qualified and insured. Returning too soon to training after exercise. Symptoms of Myositis Ossificans include: Restricted range of movement. Pain in the muscle when you use it. A hard lump in the muscle. An X ray can show bone growth. What can be done? See a sports injury specialist or doctor as soon as possible who will - Advise you to rest or immobilize the limb for 3 to 4 weeks. X-ray the muscle to see when it is safe to start rehabilitation. Operate in worst cases to remove the bone.
  • Remodelling of inert structures is by achieving normal ROM Remodelling of contractile tissues must enable tissues to be able to not only contract but also elongate Remodelling of either contractile or inert tissues can take weeks or months The greater the functional loss, the more often the pain occurs Structural changes/impairment of contractile tissues = pain on resisted movement loading at any point of ROM, but often mid range painful arc Overstretching of contracted soft tissues can cause repeated minor trauma = increased pain = rest = pain subsides = further scarring & contractures limit available range = “vicious circle”
  • Check their list
  • Sir Astley Cooper’s engravings Surgeon in London late 1700-1830’s Engravings show bodies remarkable capacity to heal itself. And thorough remodelling restore function. Process of remodelling achieved through persistent and regular movement.
  • Tendon, Muscle, and Cartilage Injuries

    1. 1. Tendon, Muscle, and Cartilage Injuries Kate Markland www.marklandclinic.com
    2. 2. Contents <ul><li>Recap biomechanics of soft tissue injury </li></ul><ul><li>Value of exercise as treatment tool </li></ul><ul><li>Tendon pathologies and treatment options </li></ul><ul><ul><li>Chronic tendinopathy </li></ul></ul><ul><ul><li>Acute rupture </li></ul></ul><ul><li>Traumatic Muscle Injuries </li></ul><ul><ul><li>Haematomas </li></ul></ul><ul><ul><li>Hamstring Injury, Micheal Owen </li></ul></ul><ul><ul><li>Complications </li></ul></ul><ul><li>Meniscal Injuries </li></ul>
    3. 3. Summary of biomechanical forces influencing soft tissue <ul><li>Connective tissue composition </li></ul><ul><ul><li>PG content, Fibre type, Fibre orientation </li></ul></ul><ul><ul><li>Structure related to function </li></ul></ul><ul><li>Mechanical forces </li></ul><ul><ul><li>Load (Stress) </li></ul></ul><ul><ul><li>Direction (Anisotropy) </li></ul></ul><ul><ul><li>Time (Viscoelastic properties, creep and hysteresis) </li></ul></ul><ul><li>Stress strain curve </li></ul>Zuener (2004) states that mechanical forces are characterized by direction, duration and intensity
    4. 4. What treatment tools does a Physiotherapist have?
    5. 5. Does it matter which tool? <ul><li>Need a reliable assessment tool based on patients characteristics </li></ul><ul><ul><li>making clinical decisions </li></ul></ul><ul><ul><li>distinguish effective, ineffective and counter productive treatments </li></ul></ul><ul><ul><li>establishing a prognosis </li></ul></ul><ul><ul><li>treating patients with regard to classification </li></ul></ul><ul><ul><li>communication between clinicians </li></ul></ul><ul><ul><li>offering an effective method of teaching students </li></ul></ul><ul><ul><li>furthering our understanding of different subgroups </li></ul></ul><ul><ul><li>audit and research </li></ul></ul><ul><li>It is important we subgroup symptoms and manage accordingly </li></ul>Donelson, R. (2004). &quot;Evidence-based low back pain classification. Improving care at its foundation.&quot; Europa Medicophysica 40 (1): 37-44. McKenzie, R.A., & May, S. (2003). The lumbar spine: Mechanical diagnosis and therapy. Waikanae, New Zealand: Spinal Publications.
    6. 6. Systematic Reviews of commonly used treatments (McKenzie & May) “ The only intervention that consistently appears beneficial across a wide range of spinal and non-spinal musculoskeletal problems is exercise”
    7. 7. There is a need for a new approach and system to treat the musculoskeletal conditions affecting the extremities The majority of approaches offer only passive therapies which have limited or contradictory evidence to support them (McKenzie & May 2000)
    8. 8. Tendon Injuries Chronic - Tendinopathy Acute - Rupture
    9. 9. Achilles Tendinopathy <ul><li>Summarise the findings of the research on chronic midportion tendionopathy by a research group lead by Håkan Alfredson, MD, University of Ume å </li></ul><ul><li>What do the researchers think is causing the pain in mid portion chronic Achilles tendinopathy? </li></ul><ul><li>What is the most effective treatment for mid portion chronic Achilles tendinopathy and why? </li></ul>
    10. 10. What is causing the pain? <ul><li>Alfredson, Thorsen , Lorentzon (1999). In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Knee Surgery, Sports Traumatology, Arthroscopy 7(6) 378-381 </li></ul>Inflammatory model Normal prostaglandin E 2 levels High glutamate levels Time to abandon the tendonitis myth = misnomer Histopathological studies never demonstrated inflammatory cells
    11. 11. Normal Tendon <ul><li>Appear glistening white </li></ul><ul><li>Tightly packed parallel bundles of collagen fibres </li></ul><ul><li>Avascular </li></ul><ul><li>Peritendinous tissue abundantly innervated </li></ul>
    12. 12. Symptomatic Tendon <ul><li>Appears Grey </li></ul><ul><li>Disordered Collagen Fibres </li></ul><ul><li>Variable Fibrosis </li></ul><ul><li>Cellular Changes </li></ul><ul><li>Increased vascularity </li></ul><ul><li>Increase in type lll (reparative) collagen </li></ul><ul><li>Inflammatory cells never found in chronic tendon problems </li></ul>
    13. 13. Eccentric loading of the Achilles tendon <ul><li>Eccentric loading with straight and bent knee </li></ul><ul><li>15 x3, 3 times per day for 3 months </li></ul><ul><li>More pain the first two weeks, the exercise must be painful </li></ul><ul><li>Excellent results (reproduced 2003) </li></ul>Alfredson, Pietilä, Jonsson et al (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine, 26: 360–366
    14. 14. Colour Doppler examination of Achilles tendons <ul><li>Normal Achilles tendon </li></ul><ul><li>No tendon changes </li></ul><ul><li>No neovascularisation </li></ul><ul><li>Chronic mid-portion </li></ul><ul><li>Achilles tendon </li></ul><ul><li>Tendon changes </li></ul><ul><li>Neovascularisation </li></ul>Öhberg, Lorentzon, Alfredson (2001). Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surgery, Sports Traumatology, Arthroscopy 9:233–238
    15. 15. Biopsy <ul><li>Neovascularisation in all painful tendons </li></ul><ul><li>Injection of local anaesthetic towards neovessels </li></ul><ul><li>The pain was temporarily abolished in all patients </li></ul>Alfredson, Öhberg, Forsgren (2003). Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis?Knee Surgery, Sports Traumatology, Arthroscopy, 11: 334-338
    16. 16. Ultrasonography & color Doppler during eccentric calf-muscle load <ul><li>Why are eccentric exercises effective? </li></ul><ul><li>Neovascularisation in normal and dorsiflexed position </li></ul><ul><li>The flow in the neovessels disappeared in the position with the ankle joint in dorsiflexion </li></ul>
    17. 17. Ultrasonography & color Doppler after eccentric calf-muscle load <ul><li>Before eccentric training </li></ul><ul><li>After eccentric training, 3,8 years (mean) </li></ul>
    18. 18. Applying to tendons in body <ul><li>Common source of chronic symptoms in extremity problems </li></ul><ul><ul><li>Sports people </li></ul></ul><ul><ul><li>Over use </li></ul></ul><ul><ul><li>Older people </li></ul></ul><ul><li>Persistent symptoms common </li></ul><ul><li>Evidence to date - more in common between different tendons than differences </li></ul><ul><li>Common links – pathophysiology and management </li></ul><ul><li>RCT problems = commonest source of shoulder pain </li></ul>
    19. 19. Loading the tissue <ul><li>Increasing evidence from a range of sites that tendon problems respond to loading </li></ul><ul><li>Evidence is sometimes rather weak methodologically, but consistent between studies and between different sites </li></ul><ul><li>Chronic problems with lots failed conservative treatment improves with loading </li></ul>(Alfredson et al 1998, Holmich et al 1999, Pienimaki et al 1996, 1998, Brox et al 1993, 1999)
    20. 20. Conclusion <ul><li>Tendon problems common source of chronic extremity problems </li></ul><ul><li>Management = loading </li></ul><ul><li>Importance of exercise for restoration of function </li></ul><ul><li>It does matter which treatment tool is used </li></ul><ul><li>Need a reliable assessment tool </li></ul>Clinical application Theory Research Tendinopathy
    21. 21. Achilles Tendon
    22. 22. Tendon Injury Classification <ul><li>Grade I -Fibres of tendon are stretched, but no tear. </li></ul><ul><li>-There is a little tenderness and swelling. </li></ul><ul><li>-The joint is not unstable. </li></ul><ul><li>Grade II -The fibres of the tendon are partially torn. </li></ul><ul><li>-There is a little tenderness and moderate swelling. </li></ul><ul><li>-The joint may feel unstable or gives way during activity, muscle strength will be reduced </li></ul><ul><li>Grade III -The fibres of the tendon are completely torn (ruptured) </li></ul><ul><li>-There is tenderness (but not a lot of pain) </li></ul><ul><li>-There may be a little swelling or a lot of swelling. </li></ul><ul><li>-No joint movement on muscle contraction </li></ul><ul><li>-Usually obvious deformity </li></ul><ul><li>-Needs surgical repair </li></ul>
    23. 23. Complete Achilles Rupture <ul><li>Thickest and strongest tendon </li></ul><ul><li>Often a history of pain but sometimes no warning </li></ul><ul><li>Most vulnerable: 2-6 cm from insertion into calcaneus </li></ul><ul><li>Average age of 40 y for complete rupture </li></ul><ul><li>Could be prevented by regular physical activity </li></ul><ul><li>Forceful muscle activation when in a stretched position </li></ul><ul><li>Thomson test is positive </li></ul><ul><li>After surgical repair, risk of recurrence is around 2%. </li></ul>
    24. 24. Ruptured and repaired Achilles Tendon <ul><li>http://www.youtube.com/watch?v=7YK_qLk1alw </li></ul>
    25. 25. Muscle injuries <ul><ul><li>Traumatic </li></ul></ul>
    26. 26. Muscle Strains and Tears <ul><li>Occurs during rapid over-stretching of the particular muscle when the muscle is forced to lengthen while it is still tenses </li></ul><ul><li>Muscle need to work in a coordinated fashion while some muscles contract (agonists) others must relax (antagonists) </li></ul><ul><li>If antagonists do not relax and lengthen sufficiently then the tense fibres will be forced to stretch and may be pulled by the action of the agonist </li></ul>
    27. 27. Muscle Tears <ul><li>Muscle fibres, connective tissue and blood vessels in the region are torn </li></ul><ul><li>Severity varies greatly (few fibres to complete tear) </li></ul><ul><li>If bleeding occurs a haematoma will form </li></ul><ul><li>Common at the myotendinous junction </li></ul>
    28. 28. Haematoma <ul><li>A bruised muscle is normally causes by an acute blow to the muscle which crushes against the underlying bone </li></ul><ul><li>Muscle fibres, connective tissue and blood vessels are damaged </li></ul><ul><li>A haematoma is a collection of blood, and can occur anywhere where bleeding occurs </li></ul>
    29. 29. There are two types of haematoma <ul><li>Intramuscular </li></ul><ul><ul><li>A tearing of the muscle within the sheath </li></ul></ul><ul><ul><li>Blood is unable to escape as the muscle sheath prevents it. </li></ul></ul><ul><ul><li>You are not likely to see any bruising </li></ul></ul><ul><li>Intermuscular </li></ul><ul><ul><li>A tearing of the muscle and part of the sheath surrounding it. </li></ul></ul><ul><ul><li>Initial bleeding will take longer to stop </li></ul></ul><ul><ul><li>However recovery is often faster than intramuscular as the blood and fluids can flow away from the site of injury. </li></ul></ul><ul><ul><li>You are more likely to see bruising </li></ul></ul>
    30. 30. Haematoma Resolution <ul><li>Typically 2 weeks to heal/disappear. </li></ul><ul><li>Healing Colour Change </li></ul><ul><ul><li>Different components of the blood have different colours </li></ul></ul><ul><ul><li>Bruises usually start out as a dark blue; fade to violet, green, and yellow finally disappearing completely. </li></ul></ul><ul><ul><li>The striking colours of a bruise are caused by haemoglobin and its breakdown products, bilirubin and biliverdin . </li></ul></ul>
    31. 31. Hamstring Injury
    32. 32. Hamstring Injury <ul><li>Risk factors? </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Injury history </li></ul></ul><ul><ul><li>Hamstring/ Quadriceps ratio (H:Q <0.60) </li></ul></ul><ul><ul><li>Lack of muscle flexibility </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><ul><li>The accumulation of lactic acid can inhibit coordination between the muscle groups </li></ul></ul></ul>
    33. 33. Michael Owen <ul><li>First injured in 1999 </li></ul><ul><li>Recurrent Hamstring injury while playing for Liverpool against Tottenham (2001) </li></ul><ul><li>Many missed games since due to recurrent problems </li></ul><ul><li>Recurrence is common an often more severe than the initial injury </li></ul><ul><li>http://www.physioroom.com/news/english_premier_league/players/1500/michael_owen_injury.html </li></ul>
    34. 34. Tissue Healing
    35. 35. Complications of Muscle Injury <ul><li>Myositis Ossificans </li></ul><ul><li>Bone formation </li></ul><ul><li>Direct trauma to the muscle that results in bleeding (haematoma formation) </li></ul><ul><li>Haematoma may become invaded by osteoblasts (calcium deposits and calcifies) </li></ul><ul><li>Can lead to muscle tethering </li></ul><ul><li>Seen on x-ray </li></ul>
    36. 36. Scaring <ul><li>Muscle fibres replaced by collagenous scar tissue </li></ul><ul><li>Scar tissue less tensile strength = recurrent injury </li></ul><ul><li>Contraction and adherence causes loss of function </li></ul><ul><li>Abnormal tissue + Normal stresses=pain </li></ul><ul><li>Pain presentation never varies </li></ul><ul><li>Normal muscle movement (contraction/stretching) is impaired </li></ul><ul><li>Pain persists until affected structures remodelled </li></ul>
    37. 37. Cartilage Injuries
    38. 38. Knee Joint Anatomy Synovial bicondylar hinge joint
    39. 39. Knee – Superior View Stump of ACL Anterior horn Posterior horn
    40. 40. Causes of meniscus tears <ul><li>Traumatic tears </li></ul><ul><li>- rotation </li></ul><ul><li>Degenerative tears </li></ul><ul><li>- failure of the meniscus over time </li></ul><ul><li>- becomes less elastic in late 20s </li></ul><ul><li>- sometimes no memorable violent events can be blamed </li></ul><ul><li>- a meniscus can tear in almost any conceivable geometric pattern </li></ul><ul><li>- anterior horn tears are unusual </li></ul><ul><li>- Typically tears begin in the posterior horn and then can extend forward into the middle body and even anterior horn. </li></ul>
    41. 41. Traumatic Meniscal tears <ul><li>Pain on the affected side of the knee </li></ul><ul><li>Mild to moderate swelling </li></ul><ul><li>Locked / pseudo-locked knee </li></ul><ul><li>Tears may become caught with the joint </li></ul><ul><li>Dislike twisting, squatting or impacting activities </li></ul><ul><li>MRI scan can assess integrity and if a tear is present. </li></ul>
    42. 42. Meniscal Blood Supply <ul><li>Only peripheral aspect of meniscus has blood supply </li></ul><ul><li>Central traumatic or degenerative tears less likely to heal </li></ul>
    43. 43. Menisectomy <ul><li>Total menisectomy </li></ul><ul><li>Partial menisectomy </li></ul><ul><li>Roos et al concluded that “meniscectomy represented a significant risk factor for radiographic osteoarthritis of the knee, being 14 times more likely in knees which had meniscectomy than in uninjured knees” </li></ul>
    44. 44. Arthroscopy Wash out & Debridement <ul><li>Local smoothing of cartilage fibrilation </li></ul><ul><li>Aim to reduce friction occuring at the roughened surfaces and the associated inflammatory response </li></ul><ul><li>Treatment for early OA changes grade I – II </li></ul><ul><li>Improves symptoms of catching </li></ul><ul><li>Temporary </li></ul><ul><li>No evidence shaving will result in healing </li></ul>
    45. 45. Meniscal Repair <ul><li>Meniscal tears within the peripheral vascular area may eventually heal </li></ul><ul><li>Meniscus can be sutured to immobilise the torn segment to encourage healing </li></ul>
    46. 50. References <ul><li>Alfredson, Öhberg, Forsgren (2003). Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis?Knee Surgery, Sports Traumatology, Arthroscopy, 11: 334-338 </li></ul><ul><li>Alfredson, Pietilä, Jonsson et al (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine, 26: 360–366 </li></ul><ul><li>Alfredson, Thorsen , Lorentzon (1999). In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Knee Surgery, Sports Traumatology, Arthroscopy 7(6) 378-381 </li></ul><ul><li>Asklinh et al (2006) Type of Acute Hamstring Strain Affects Flexibility, Strength, and Time to Return to Pre-Injury Level, British Journal of Sports Medicine, 40, pp. 40-44. </li></ul><ul><li>Briggs, J. (2001) Sports Therapy: Theoretical and Practical Thoughts and Considerations, Chichester: Corpus Publishers. </li></ul>
    47. 51. <ul><li>Culav, E., Clark, H., & Merrilees, M. (1999). Connective tissues: matrix compostion and its relevance to physical therapy. Physical Therapy, 79 (3), 308-319. </li></ul><ul><li>Hoskins and Pollard (2005) Hamstring Injury Management- Part 1Issues in Diagnosis, Manual Therapy, pp.96-107. </li></ul><ul><li>Hoskins and Pollard (2005) Hamstring Injury Management- Part 2 Treatment, Manual Therapy, pp.180-190. </li></ul><ul><li>Öhberg, Lorentzon, Alfredson (2001). Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surgery, Sports Traumatology, Arthroscopy 9:233–238 </li></ul><ul><li>Read, M. (2000) A Practical Guide to Sports Injuries, Chapter 17, pp. 199-203 </li></ul><ul><li>Tortora. G, Grabowski. S (1996) Principles of Anatomy and Physiology ,Harlow: Harper Collins. </li></ul><ul><li>Threlkeld, A (1992). The effects of manual therapy on connective tissue. Physical Therapy, 72(12), 893-902. </li></ul><ul><li>Zeuner, J. (2004). The effects of mechanical therapy on tissue repair and remodelling. The McKenzie Institute USA Journal, 12(3), 19-25. </li></ul>References