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Biomechanical overload syndrome: Defining a new diagnosis

Authors:
Andrew Franklyn-Miller at Nuritas Inc.
Andrew Franklyn-Miller
Andrew Roberts at Ministry of Defence uk
Andrew Roberts
David Hulse
David Hulse
David Hulse
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John Foster at InformRunning
John Foster
  • InformRunning
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... The diagnosis of chronic exertional compartment syndrome (CECS) dates back to 1956 [40], and is said to mostly affect young active runners, elite athletes, and those involved in the military [41]. The majority of CECS cases (95%) occur in the anterior and lateral compartments of the leg [41]. ...
... The leading mechanistic theory is said to be from poor fascial compliance which can lead to high subfascial and/or intramuscular pressures causing decreased blood flow to the working muscles leading to hypoxia and the subsequent experience of local muscle hypoxia [41,42]. Despite the widespread use of CECS as a diagnosis, there remains a great deal unknown about its onset-namely, the inconsistencies in diagnostic intracompartmental pressure testing and the high number of failed fasciotomies [40,43]. ...
... More recently, research has started to evaluate possible kinematic causes of anterior exertional shin pain. This has involved a reconceptualization from CECS to local muscular overload, and hence termed anterior biomechanical overload syndrome (ABOS) [40,42]. The clinical reasoning behind this suggests that with excessive ankle dorsi flexion at foot strike (exemplified clinically by an excessive heel strike and/or excessive stride length), the anterior compartment muscles of the leg become overloaded and fatigued, hence causing the CECS-like symptoms in the anterior compartment [40,42]. ...
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... It has been speculated that tight hip flexors may cause reliance on secondary hip extensors, potentially provoking greater stress on the hamstrings (17,(25)(26)(27). Over activation of the hamstrings has been linked to those with lower extremities injuries (28)(29)(30). ...
The Effect of Restricted Hip Extension on Muscle Activity During Functional Movements
Article
Full-text available
  • Mar 2024
Background: Hip flexor tightness is a common problem affecting both active and sedentary individuals and can lead to the development of movement deficiencies potentially resulting in altered muscle activity around the hip joint. The overhead squat, inline lunge, and single leg step-up are common functional movements used to asses for movement deficiencies. The purpose of the study was to compare surface electromyography (sEMG) in the rectus femoris (RF), gluteus maximus (GM), biceps femoris (RF), and semitendinosus (ST) muscles and GM:BF co-activation ratio during the over-head squat, in-line lunge, and step-up between healthy females with and without hip flexor tightness. Methods: Participants were screened for hip flexor tightness using the modified Thomas Test and classified into a tight hip flexor and non-tight hip flexor group. Muscle activity data was collected using sEMG on the RF, GM, BF, and ST muscles during three functional movements: the over-head squat, in-line lunge, and step-up. Results: There were no statically significant differences in muscles between those with hip flexor tightness and healthy controls during the three tested movements. However, those with hip flexor tightness displayed greater hamstring utilization during all movements (Hedges g = 0.37 - 0.73). Conclusions: Those who have hip flexor tightness appear to adopt a more hamstring-based movement strategy to complete functional movements. More research is warranted to determine the extent to which hip flexor tightness affects functional movement patterns and muscle activity surrounding the hip joint.
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... Different gait patterns may reflect different methods of load distribution, resulting in injury, or they may be the result of alterations due to pain response or neuromuscular dysfunction in response to existing pathology. For example, differences in structure-specific loading in frontal or sagittal planes may explain the increase in hip and shin injury incidence, respectively [20,34,61,62], or result from compensation for pain or weakness [63,64]. Therefore, without further prospective evidence we cannot establish whether specific biomechanical presentations can represent the specific RRI, or whether the same RRIs present with the same gait pattern. ...
Running-Related Injury Incidence: Does It Correlate with Kinematic Sub-groups of Runners? A Scoping Review
Article
Full-text available
  • Jan 2024
  • SPORTS MED
Background Historically, kinematic measures have been compared across injured and non-injured groups of runners, failing to take into account variability in kinematic patterns that exist independent of injury, and resulting in false positives. Research led by gait patterns and not pre-defined injury status is called for, to better understand running-related injury (RRI) aetiology and within- and between-group variability. Objectives Synthesise evidence for the existence of distinct kinematic sub-groups across a population of injured and healthy runners and assess between-group variability in kinematics, demographics and injury incidence. Data Sources Electronic database search: PubMed, Web of Science, Cochrane Central Register of Controlled Trials (Wiley), Embase, OVID, Scopus. Eligibility Criteria Original, peer-reviewed, research articles, published from database start to August 2022 and limited to English language were searched for quantitative and mixed-methods full-text studies that clustered injured runners according to kinematic variables. Results Five studies (n = 690) were included in the review. All studies detected the presence of distinct kinematic sub-groups of runners through cluster analysis. Sub-groups were defined by multiple differences in hip, knee and foot kinematics. Sex, step rate and running speed also varied significantly between groups. Random injury dispersal across sub-groups suggests no strong evidence for an association between kinematic sub-groups and injury type or location. Conclusion Sub-groups containing homogeneous gait patterns exist across healthy and injured populations of runners. It is likely that a single injury may be represented by multiple movement patterns, and therefore kinematics may not predict injury risk. Research to better understand the underlying causes of kinematic variability, and their associations with RRI, is warranted.
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... Several strategies for the prevention and treatment of running injuries are applied by coaches and runners themselves; these include stretching, warming up, technical training, and changing the running technique (called retraining) to reduce the load on certain muscle groups and joints [17]. Biomechanical studies have extensively examined running retraining strategies that include changes in the step cadence, stride length, distance between the heel and the center of mass at the initial foot contact with the ground, duration of flight phase, foot strike pattern, hip and knee movement, trunk position, step width, and impact load variables, among others; these studies also reported changes in the variables of kinematics, kinetics, and electromyography [18]. ...
Effectiveness of Lower-Cost Strategies for Running Gait Retraining: A Systematic Review
Article
Full-text available
  • Jan 2023
The effectiveness of lower-cost equipment used for running gait retraining is still unclear. The objective of this systematic review was to evaluate the effectiveness of lower-cost equipment used in running gait retraining in altering biomechanical outcomes that may be associated with injuries. The literature search included all documents from MEDLINE, Web of Science, CINAHL, SPORTDiscus, and Scopus. The studies were assessed for risk of bias using an evaluation tool for cross-sectional studies. After screening 2167 initial articles, full-text screening was performed in 42 studies, and 22 were included in the systematic review. Strong evidence suggested that metronomes, smartwatches, and digital cameras are effective in running gait retraining programs as tools for intervention and/or evaluation of results when altering step cadence and foot strike patterns. Strong evidence was found on the effectiveness of accelerometers in interventions with feedback to reduce the peak positive acceleration (PPA) of the lower leg and/or footwear while running. Finally, we found a lack of studies that exclusively used lower-cost equipment to perform the intervention/assessment of running retraining.
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Running Biomechanics and Clinical Features Among Adolescent Athletes With Lower Leg Chronic Exertional Compartment Syndrome
Article
  • Apr 2024
Objective To compare clinical measures between patients with chronic exertional compartment syndrome (CECS) and healthy controls and evaluate running biomechanics, physical measurements, and exertional intracompartmental (ICP) changes in adolescent athletes with lower leg CECS. Design Cross-sectional case–control study. Setting Large tertiary care hospital and affiliated injury prevention center. Participants Forty-nine adolescents with CECS (39 F, 10 M; age: 16.9 ± 0.8 years; body mass index (BMI): 23.1 ± 2.9 kg/m ² ; symptom duration: 8 ± 12 months) were compared with 49 healthy controls (39 F, 10 M; age: 6.9 ± 0.8 years; BMI: 20.4 ± 3.7 kg/m ² ). Interventions All participants underwent gait analyses on a force plate treadmill and clinical lower extremity strength and range of motion testing. Patients with chronic exertional compartment syndrome underwent Stryker monitor ICP testing. Main Outcome Measures Symptoms, menstrual history, and ICP pressures of the patients with CECS using descriptive statistics. Mann–Whitney U and χ ² analyses were used to compare CECS with healthy patients for demographics, clinical measures, and gait biomechanics continuous and categorical outcomes, respectively. For patients with CECS, multiple linear regressions analyses were used to assess associations between gait biomechanics, lower extremity strength and range of motion, and with ICP measures. Results The CECS group demonstrated higher mass-normalized peak ground reaction force measures (xBW) compared with controls (0.21 ± 0.05 xBW ( P < 0.001) and were more likely to have impact peak at initial contact ( P = 0.04). Menstrual dysfunction was independently associated with higher postexertion ICP (ß = 14.6; P = 0.02). Conclusions The CECS group demonstrated increased total force magnitude and vertical impact transient peaks. In women with CECS, menstrual dysfunction was independently associated with increased postexertion ICP. These biomechanical and physiological attributes may play a role in the development of CECS.
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Differences between lower extremity joint running kinetics captured by marker-based and markerless systems were speed dependent
Article
Full-text available
  • Jan 2024
Background The development of computer vision technology has enabled the use of markerless movement tracking for biomechanical analysis. Recent research has reported the feasibility of markerless systems in motion analysis but has yet to fully explore their utility for capturing faster movements, such as running. Applied studies using markerless systems in clinical and sports settings are still lacking. Thus, the present study compared running biomechanics estimated by marker-based and markerless systems. Given running speed not only affects sports performance but is also associated with clinical injury prevention, diagnosis, and rehabilitation, we aimed to investigate the effects of speed on the comparison of estimated lower extremity joint moments and powers between markerless and marker-based technologies during treadmill running as a concurrent validating study. Methods Kinematic data from marker-based/markerless technologies were collected, along with ground reaction force data, from 16 young adults running on an instrumented treadmill at 3 speeds: 2.24 m/s, 2.91 m/s, and 3.58 m/s (5.0 miles/h, 6.5 miles/h, and 8.0 miles/h). Sagittal plane moments and powers of the hip, knee, and ankle were calculated by inverse dynamic methods. Time series analysis and statistical parametric mapping were used to determine system differences. Results Compared to the marker-based system, the markerless system estimated increased lower extremity joint kinetics with faster speed during the swing phase in most cases. Conclusion Despite the promising application of markerless technology in clinical settings, systematic markerless overestimation requires focused attention. Based on segment pose estimations, the centers of mass estimated by markerless technologies were farther away from the relevant distal joint centers, which led to greater joint moments and powers estimates by markerless vs. marker-based systems. The differences were amplified by running speed.
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Mechanische Eigenschaften der Arterien
Article
  • Sep 2023
Zusammenfassung Dieser Artikel beschäftigt sich mit den biomechanischen Eigenschaften der Arterien und dem Einfluss des perivaskulären Gewebes auf die Durchblutung. Es wird erläutert, wie die Arterien in ihrer Umgebung stabilisiert sind, wie sie sich gegenüber der Umgebung bewegen und wie sich das perivaskuläre Gewebe und die Arterien gegenseitig beeinflussen. Anschließend wird, abgeleitet aus der embryologischen Entwicklung, eine Referenzposition für die unteren Extremitäten vorgeschlagen. Am Ende des Artikels werden am Beispiel der unteren Extremität osteopathische Techniken gezeigt, welche die biomechanische Integration der Beinarterien als Ziel haben.
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Chronic Leg Pain in Running Athletes
Chapter
  • May 2023
Chronic leg pain is a common problem found in running athletes that can pose challenges for both patient and providers. Metabolic, osseous, soft tissue, and neurovascular etiologies have been implicated. Though common, the presentation of these pathologies can at times be vague and overlapping with reported intermixed symptoms of pain, weakness, numbness, or tingling. This can lead to clinical difficulty in arriving at the proper diagnosis and suggesting the optimal treatment of these conditions. In this chapter, causes of chronic leg pain in running athletes will be reviewed including its clinical presentation, diagnostic evaluation, as well as targeted treatment options with the goal of offering providers a thorough understanding of these pathologies to aid in their practice.KeywordsRunningAthleteLeg painStress fractureChronic painExertional compartment syndromeNerve entrapment|Tibial stress syndrome
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Running Speed Exacerbates Lower Extremity Joint Moment and Power Differences Estimated by Marker-based and Markerless Motion Capture Systems
Preprint
Full-text available
  • Mar 2023
The development of computer vision technology has enabled the use of Markerless (ML) movement tracking for biomechanical analysis. Recent research has reported the reliability of ML in motion analysis but has not yet further explored the clinical potential and limitations. The purpose of this study was to investigate the effects of speed on the comparison of estimated lower extremity joint moments and powers between ML and marker-based (MB) technologies during treadmill running. Kinematic data of both MB/ML and ground reaction force data were collected from 16 recreational young adults running on an instrumented treadmill for 120 s at three speeds: 2.24 m/s, 2.91 m/s, and 3.58 m/s. Three-dimensional moments and powers of the hip, knee, and ankle were calculated. Compared to the MB, ML estimated greater increased hip and knee joint kinetics with faster speeds during the swing. Additionally, increased greater ankle joint moments with increased speeds estimated by ML were observed during early swing. In contrast, greater ankle joint power occurred during the initial stance. Despite the promising application of ML technology in clinical settings, systematic ML overestimation requires extra attention. These observations may indicate that inconsistent segment pose estimations (mainly the center of mass estimated by ML being farther away from the relevant distal joint center) might lead to systematic differences in joint moments and powers estimated by MB versus ML.
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Forefoot Running Improves Pain and Disability Associated With Chronic Exertional Compartment Syndrome
Article
Full-text available
  • Mar 2012
Anterior compartment pressures of the leg as well as kinematic and kinetic measures are significantly influenced by running technique. It is unknown whether adopting a forefoot strike technique will decrease the pain and disability associated with chronic exertional compartment syndrome (CECS) in hindfoot strike runners. For people who have CECS, adopting a forefoot strike running technique will lead to decreased pain and disability associated with this condition. Case series; Level of evidence, 4. Ten patients with CECS indicated for surgical release were prospectively enrolled. Resting and postrunning compartment pressures, kinematic and kinetic measurements, and self-report questionnaires were taken for all patients at baseline and after 6 weeks of a forefoot strike running intervention. Run distance and reported pain levels were recorded. A 15-point global rating of change (GROC) scale was used to measure perceived change after the intervention. After 6 weeks of forefoot run training, mean postrun anterior compartment pressures significantly decreased from 78.4 ± 32.0 mm Hg to 38.4 ± 11.5 mm Hg. Vertical ground-reaction force and impulse values were significantly reduced. Running distance significantly increased from 1.4 ± 0.6 km before intervention to 4.8 ± 0.5 km 6 weeks after intervention, while reported pain while running significantly decreased. The Single Assessment Numeric Evaluation (SANE) significantly increased from 49.9 ± 21.4 to 90.4 ± 10.3, and the Lower Leg Outcome Survey (LLOS) significantly increased from 67.3 ± 13.7 to 91.5 ± 8.5. The GROC scores at 6 weeks after intervention were between 5 and 7 for all patients. One year after the intervention, the SANE and LLOS scores were greater than reported during the 6-week follow-up. Two-mile run times were also significantly faster than preintervention values. No patient required surgery. In 10 consecutive patients with CECS, a 6-week forefoot strike running intervention led to decreased postrunning lower leg intracompartmental pressures. Pain and disability typically associated with CECS were greatly reduced for up to 1 year after intervention. Surgical intervention was avoided for all patients.
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Long-term Results of Surgical Decompression of Chronic Exertional Compartment Syndrome of the Forearm in Motocross Racers
Article
Full-text available
  • Feb 2012
Chronic exertional compartment syndrome (CECS) is occasionally observed in the forearm flexor muscles of motocross racers. Long-term results of fasciectomy and fasciotomy for this syndrome are scarce. To study the long-term effects of 2 surgical techniques for forearm flexor CECS. Case series; Level of evidence, 4. A database of patients with forearm CECS who underwent surgery was analyzed. Long-term pain reduction (visual analog scale [VAS], 0-100) and efficacy were evaluated using a questionnaire. Data of 24 motocross racers were available for analysis. Intracompartmental pressures during rest, during provocation, and after 1 and 5 minutes of provocation were 15 ± 4, 78 ± 24, 29 ± 10, and 25 ± 7 mm Hg, respectively. Painful sensations in the forearm were reduced from 53 to 7 (median VAS; P < .001). Both fasciectomy (n = 14) and fasciotomy (n = 10) were equally effective. More than 95% (23/24) of the patients were satisfied with the postoperative result after 5 ± 2 years' follow-up. Surgical fasciotomy and fasciectomy of the forearm flexor compartment are equally successful in motocross racers suffering from forearm CECS.
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Sensory innervation of the thoracolumbar fascia in rats and humans
Article
Full-text available
  • Aug 2011
The available data on the innervation of the thoracolumbar fascia (TLF) are inconsistent and partly contradictory. Therefore, the role of the fascia as a potential source of pain in the low back is difficult to assess. In the present study, a quantitative evaluation of calcitonin gene-related peptide (CGRP) and substance P (SP)-containing free nerve endings was performed in the rat TLF. A preliminary non-quantitative evaluation was also performed in specimens of the human TLF. The data show that the TLF is a densely innervated tissue with marked differences in the distribution of the nerve endings over the fascial layers. In the rat, we distinguished three layers: (1) Outer layer (transversely oriented collagen fibers adjacent to the subcutaneous tissue), (2) middle layer (massive collagen fiber bundles oriented obliquely to the animal's long axis), and (3) inner layer (loose connective tissue covering the paraspinal muscles). The subcutaneous tissue and the outer layer showed a particularly dense innervation with sensory fibers. SP-positive free nerve endings-which are assumed to be nociceptive-were exclusively found in these layers. Because of its dense sensory innervation, including presumably nociceptive fibers, the TLF may play an important role in low back pain.
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Chronic exertional compartment syndrome of the foot
Article
  • Feb 2011
In this paper the authors present a case history along with results of case series and a literature review to demonstrate the complexity of this condition. The main aim is to increase the awareness among clinicians and the scientist to research in the area of chronic exertional compartment syndrome (CECS). CECS usually refers to myoneural ischaemia due to a reversible increase in tissue pressure within a myofascial compartment. CECS of the leg is well documented in the literature since it was first described by Mavor in 1956. CECS of the foot remains underdiagnosed and has been reported in the literature only on an anecdotal basis. Wood Jones proposed that there were four compartments in the foot but Manoli and Weber suggest that there are nine separate muscle compartments. Clinical signs and symptoms of CECS of the foot remain diverse and lack the consistency of its counter part in the leg. The range of signs and symptoms include swelling, tension, cramps, tightness, paraesthesia, numbness, cyanosis and soft tissue indurations. As a result number of diagnosis is first considered and includes plantar fasciitis, tibialis posterior tendonitis, tarsal tunnel syndrome and medial Lisfranc injury. CECS of the foot remains a diagnosis of exclusion. The most effective treatment is a superficial fasciotomy.
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Endurance Running and the Evolution of Homo
Article
  • Dec 2004
Striding bipedalism is a key derived behaviour of hominids that possibly originated soon after the divergence of the chimpanzee and human lineages. Although bipedal gaits include walking and running, running is generally considered to have played no major role in human evolution because humans, like apes, are poor sprinters compared to most quadrupeds. Here we assess how well humans perform at sustained long-distance running, and review the physiological and anatomical bases of endurance running capabilities in humans and other mammals. Judged by several criteria, humans perform remarkably well at endurance running, thanks to a diverse array of features, many of which leave traces in the skeleton. The fossil evidence of these features suggests that endurance running is a derived capability of the genus Homo, originating about 2 million years ago, and may have been instrumental in the evolution of the human body form.
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On the epidemiology of running injuriesThe 1984 Bern GrandPrix study
Article
  • Jun 1988
  • AM J SPORT MED
Using a survey questionnaire design, we investigated the incidence, site, and nature of jogging injuries among all participants of a popular 16 km race. The response rate was 83.6%. Of 4,358 male joggers, 45.8% had sustained jogging injuries during the 1 year study period, 14.2% had required medical care, and 2.3% had missed work because of jogging injuries. Occur rence of jogging injuries was independently associated with higher weekly mileage (P < 0.001), history of previous running injuries (P < 0.001), and competitive training motivation (P = 0.03). Higher mileage was also associated with more frequent medical consultations due entirely to jogging-related injuries. In 33 to 44 year olds (N = 1,757), the number of years of running was inversely related to incidence of injuries (P = 0.02). Injuries were not significantly related to race running speed, training surface, characteristics of running shoes, or relative weight. Achillodynia and calf muscle symptoms were the two most common overuse injuries and occurred significantly more often among older run ners with increased weekly mileage. We conclude that jogging injuries are frequent, that the number of firmly established etiologic factors is low, and that, in recom mending jogging, moderation should be the watchword.
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The effects of elevated compartment pressure on tibial arteriovenous flow and relationship of mechanical and biochemical characteristics of fascia to genesis of chronic anterior compartment syndrome
Article
  • Jun 1995
  • J VASC SURG
Purpose: The purpose of this study is to evaluate the effects of increased compartment pressure on anterior tibial arteriovenous flow patterns and to determine whether mechanical and biochemical properties of fascia are responsible for compartment pressure abnormalities. Methods: Twenty patients with chronic anterior compartment syndrome (CACS) and 20 age-matched control subjects had compartment pressure measurements and analysis of tibial arterial and venous flow before and after fasciectomy. Fascia specimens were evaluated for thickness, stress failure, structural stiffness, and total collagen content and prevalence of collagen cross-linkage. Results: Pressures were significantly elevated in patients with CACS versus control subjects (23.8 mm Hg vs 6 mm Hg). No significant difference in tibial arterial flow could be detected in either group (43 cm/sec mean vs 41.9 cm/sec mean). Venous drainage was severely impaired in patients with CACS but not in control subjects. CACS fascia was thicker and stiffer than control fascia specimens (0.35 mm +/- 0.12 mm, 109 +/- 65 MN/mm; versus 0.22 mm +/- 0.06 mm; 60.3 +/- 22 MN/mm). Fasciectomy normalized postoperative compartment pressures and improved venous drainage. Collagen content per unit mass was similar for both CACS and control fascia specimens, although collagen cross-linking was significantly lower in the CACS fascia than in the controls. Conclusions: Tibial venous drainage is impaired, but arterial flow is not in patients with CACS. Fascia thickness and structural stiffness can account for increased pressure in CACS compartments. Collagen content and cross-linkage are unrelated to fascia stiffness or thickness. Postoperative improvement in vascular hemodynamics and reduction in compartment pressure is caused by increased capacitance in the compartment after fasciectomy.
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Foot Strike and Injury Rates in Endurance Runners: A Retrospective Study
Article
  • Jan 2012
  • MED SCI SPORT EXER
This retrospective study tests if runners who habitually forefoot strike have different rates of injury than runners who habitually rearfoot strike. We measured the strike characteristics of middle- and long-distance runners from a collegiate cross-country team and quantified their history of injury, including the incidence and rate of specific injuries, the severity of each injury, and the rate of mild, moderate, and severe injuries per mile run. Of the 52 runners studied, 36 (69%) primarily used a rearfoot strike and 16 (31%) primarily used a forefoot strike. Approximately 74% of runners experienced a moderate or severe injury each year, but those who habitually rearfoot strike had approximately twice the rate of repetitive stress injuries than individuals who habitually forefoot strike. Traumatic injury rates were not significantly different between the two groups. A generalized linear model showed that strike type, sex, race distance, and average miles per week each correlate significantly (P < 0.01) with repetitive injury rates. Competitive cross-country runners on a college team incur high injury rates, but runners who habitually rearfoot strike have significantly higher rates of repetitive stress injury than those who mostly forefoot strike. This study does not test the causal bases for this general difference. One hypothesis, which requires further research, is that the absence of a marked impact peak in the ground reaction force during a forefoot strike compared with a rearfoot strike may contribute to lower rates of injuries in habitual forefoot strikers.
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The validity of the diagnostic criteria used in chronic exertional compartment syndrome: A systematic review
Article
  • Sep 2011
  • SCAND J MED SCI SPOR
Chronic exertional compartment syndrome (CECS) of the lower limb is part of a group of overuse lower limb injuries with common presenting features. It is commonly diagnosed by the measurement of raised intramuscular pressures in the lower limb. The pathophysiology of the condition is poorly understood, and the criteria used to make the diagnosis are based on small sample sizes of symptomatic patients. We carried out a systematic review to compare intramuscular pressures in the anterior compartment of healthy subjects with commonly used criteria for CECS. Thirty-eight studies were included. With the exception of relaxation pressure, the current criteria for diagnosing CECS, considered to be the gold standard, overlap the range found in normal healthy subjects. Several studies reported mean pressures that would prompt a positive diagnosis for CECS, despite none of the subjects reporting any symptoms. The intramuscular pressure at all time points has also shown to vary in relation to a number of other factors other than the presence of CECS. Taken together, these data have major implications on the ability to use these published criteria for diagnosis and question the underlying pathophysiology. Clinicians are recommended to use protocol-specific upper confidence limits to guide the diagnosis following a failed conservative management.
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