![Page 1: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/1.jpg)
Knee Sport Injury
![Page 2: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/2.jpg)
Common Types of Sports Injuries
Muscle sprains and strains
Tears of the ligaments that hold joints together
Tears of the tendons that support joints and allow them to move
Dislocated joints
Fractured bones
![Page 3: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/3.jpg)
Major ligaments
Anterior cruciate ligament (ACL)
Posterior cruciate ligament (PCL)
Medial collateral ligament (MCL)
Lateral collateral ligament (LCL)
![Page 4: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/4.jpg)
![Page 5: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/5.jpg)
Grading of ligamentous injury
Grade 1 : no ligamentous tear, swelling , localized tenderness
Grade 2 : stretching and partial tear, marked swelling
Grade 3 : complete tear
![Page 6: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/6.jpg)
Anterior cruciate ligament
• Prevent anterior displacement of tibia, hyperextension of knee joint
• Especially in contact sports and those that involve fast changes in direction and twisting and pivoting movements
• ACL has serious implications for the stability and function of the knee joint.
![Page 7: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/7.jpg)
ACL injury
Common knee injury amongst sports people
Twisting force being applied to the knee whilst the foot is firmly planted on the ground or upon landing
Direct blow to the knee, usually the outside, during a football or rugby tackle
Combination with a medial menicus tear and MCL injury, which is termed O’Donohue triad
![Page 8: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/8.jpg)
Signs&Symptom
audible pop or crack at the time of injury
Painful
Swelling of the knee, usually immediate and extensive
Restricted movement, especially an inability to fully straighten the leg
Positive signs in the anterior drawer test and Lachman's test.
Tenderness at the medial side of the joint
![Page 9: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/9.jpg)
ACL Injury
![Page 10: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/10.jpg)
Lachman test
Bend the knee to about 30 degrees. Then, stabilize the femur with one hand. Place the other hand behind the proximal tibia at the level of the joint line and then pull forward.
![Page 11: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/11.jpg)
Grading of lachman test
Normal laxity is 0
Grade 1: Less than 0.5 cm of translation
Grade 2: 0.5-1.0 cm of translation
Grade 3: 1.0-1.5 cm of translation
![Page 12: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/12.jpg)
Anterior drawer test
![Page 13: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/13.jpg)
MCL injury
![Page 14: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/14.jpg)
MCL injury
Prevent against a valgus force and external rotation
![Page 15: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/15.jpg)
MCL injury
Most frequently injured ligament in the knee Typically due to valgus forces Usually no joint effusion
![Page 16: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/16.jpg)
MCL injuryDegree of injuryGrade I
Swelling, localized tenderness < 5 mm valgus
Grade II
Marked swelling
5-10 mm valgus
Partial tear
Grade III > 10 mm valgus
complete tear
![Page 17: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/17.jpg)
MCL injury
Diagnosis Approach Lower lateral thigh or upper medial leg
Bruising seen in gr III
Positive valgus stress test
![Page 18: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/18.jpg)
![Page 19: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/19.jpg)
Diagnostic Imaging
Pellegrini-Stieda lesion
![Page 20: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/20.jpg)
LCL Injury
![Page 21: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/21.jpg)
LCL Injury
Varus forces and external rotation of the tibia
![Page 22: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/22.jpg)
LCL Injury
Typically due to varus forces Usually occur during contact sports Typically has limited joint effusion since it is
located outside of the joint capsule
![Page 23: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/23.jpg)
LCL Injury
Diagnosis Approach
Blow to medial knee with resulting varustension forces
Positive varus stress test
![Page 24: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/24.jpg)
![Page 25: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/25.jpg)
PCL Injury
Functions:◦ Against posterior movement of the tibia on the femur
◦ Prevents flexion, extension, and hyperextension
![Page 26: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/26.jpg)
PCL Injury
Two bundles◦ Anterolateral, taut in flexion◦ Posteromedial, taut in
extension
PCL larger & stronger than ACL
![Page 27: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/27.jpg)
PCL Injury Hyper-flexion, or the
tibia being forced posteriorly on the femur
Isolated PCL Injuries unusual
![Page 28: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/28.jpg)
Posterior Drawer Test
![Page 29: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/29.jpg)
Posterior Sag Test
Posterior tibial translation
Tibia drops back on the femur
![Page 30: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/30.jpg)
Godfrey’s Test
Positive test is a posterior displacement of the tibial tuberosity
![Page 31: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/31.jpg)
Diagnostic Imaging
![Page 32: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/32.jpg)
Meniscus
2 semilunar wedges in the knee joint positioned between the tibia and the femur
deepen the articular surfaces of flat tibialplateau to accommodate the relatively round femoral condyles
![Page 33: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/33.jpg)
Meniscus Medial : semicircular or C-shaped
Lateral : circular or O-shaped
![Page 34: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/34.jpg)
Meniscus
Increased joint stability, increased congruence and conformity between the femoral condyles and tibial plateaus
wedge-shaped meniscus attached to the tibia serves as a secondary stabilizer
![Page 35: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/35.jpg)
classification of meniscal tears
longitudinal tears
radial tears
oblique flap tears
horizontal tears
complex tears
![Page 36: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/36.jpg)
Meniscal injury
sudden twist or repeated squatting
most commonly associated ligamentous disruption is complete tear of the ACL
![Page 37: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/37.jpg)
Sign&Symptom
Pain is usually localized to the joint line
Swelling usually occurs as a delayed symptom
Joint line tenderness
Joint Effusion
Mechanical block to motion
Limited ROM
![Page 38: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/38.jpg)
The McMurray test
valgus stress and
rotate externally while
extending the knee→Medial meniscus
Varus stress and
rotate internally while
extending knee →Lateral meniscus
![Page 39: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/39.jpg)
The Steinmann test
Internal rotate → Lateral meniscus
External rotate → Medial meniscus
![Page 40: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/40.jpg)
The Apley test
![Page 41: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/41.jpg)
Investigation
Plain x-ray : for excluding fracture, avulsion fracture or osteochondral fracture
MRI : soft tissue, ligament, meniscus or bony lesion. More useful in evaluation of severity, treatment and prognosis.
Arthroscopy : diagnostic and therapeutic investigation
![Page 42: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/42.jpg)
Activity level
Level 1: jumping , pivoting (football, soccer)
Level 2 : heavy manual work or side to side sport (skiing, tennis)
Level 3 light manual work or noncutting sport (jogging, running)
Level 4 : sedentary activity without sport (office worker)
Non operative treatment
Operative treatment
![Page 43: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/43.jpg)
Treatment of knee injuries
Self help
Medicines
Rehabilitaion Surgery
![Page 44: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/44.jpg)
Treatment of knee injuries
Self help “PRICE”
Protection- Protect your injury from further harm.
Rest-Rest the injury for the first two to three days
Ice- Cold compress to help reduce swelling and bruising.
Compression- Compress the joint by bandaging it to support the injury and help decrease swelling.
Elevation- Elevate knee
![Page 45: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/45.jpg)
Medicines
Painkillers
- Acetaminophen
- NSAIDs- Narcotic anlagesics
![Page 46: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/46.jpg)
Rehabilitation
stretching and strengthening exercises
goal of knee rehab : prevent weakening of the muscles surrounding the knee
diminish the burden on the knee joint
strong muscles of the leg better support and control the knee joint
quadriceps, hamstring, and calf muscles
![Page 47: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/47.jpg)
Surgery
ACL Preinjury activity level
Desire to return to high-demand sports (eg, basketball, football, soccer)
Associated injuries
Abnormal laxity
Patient's expectations
![Page 48: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/48.jpg)
Surgery
ACL surgical intervention be delayed at least 3
weeks following injury to prevent the complication of arthrofibrosis
3 groups methods of surgical repair
![Page 49: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/49.jpg)
Surgery
ACL Primary repair is not recommended except
for bony avulsions
Extra-articular repair prevent a pivot shift but has not decrease anterior tibialtranslation
Intra-articular reconstruction of the ACL
- Bone-patella-bone autografts
- Hamstring tendon grafts
- Synthetic grafts
- Allografts
![Page 50: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/50.jpg)
Surgery
MCL
grade 3 tears were treated operatively but currently are routinely treated nonoperatively
bracing with a hinged knee orthosis
![Page 51: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/51.jpg)
Surgery
LCL Grade III tears usually involve a tear in
the posterolateral capsular complex
![Page 52: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/52.jpg)
Surgery
PCL Posterior tibial translation > 10-15
mm PDT Knee flexion 90 Bony avulsion
![Page 53: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/53.jpg)
Surgery
Meniscus
symptoms persist
locked knee
longer than 1 cm
involve greater than 50% of the meniscal thickness
![Page 54: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/54.jpg)
Surgery
damaged anterior cruciate ligament in athletes
more than one ligament or tissue has been damaged
torn patellar tendon
remains painful or locks after a meniscus injury
LCL Grade III tears usually involve a tear in the posterolateral capsular complex
![Page 55: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/55.jpg)
Prevention
Do warm up exercises
Don't overdo
Cool down following vigorous sports
Wear properly fitting shoes that provide shock absorption and stability
When jumping, land with knees bent
![Page 56: Knee Sport Injury injury.pdf · Treatment of knee injuries Self help “PRICE” Protection-Protect your injury from further harm. Rest-Rest the injury for the first two to three](https://reader034.vdocuments.us/reader034/viewer/2022042303/5eceebe10430b2253d4acfeb/html5/thumbnails/56.jpg)
Thank You