Effects of long term bed rest on stretch reflex responses of elbow flexor muscles

Stretch reflex responses of m. biceps brachii and m. brachioradialis of ten normal adults were studied before and after 20 days of strict bed rest. A standard torque perturbation (15 Nm, 170 ms) was applied to the forearm to induce reflex electromyographic (EMG) activities of the two muscles investigated. Totally 30 perturbations were applied during submaximal isometric elbow flexion movements at 80 deg flexed joint angle, and ensemble averaged EMG waveforms were calculated by aligning the signal to the onset of perturbations. All subjects showed that both short and long latency stretch reflex FMG activities of m. biceps brachii were reduced immediately after 20 days bed rest, and then recovered gradually to pre-bed rest levels at one- to two-months after bed rest, whereas there was no such variation in the stretch reflex induced in m. brachioradialis. It was demonstrated that the muscle stretch reflex gain might be reduced with long-term inactivity, but the effects on stretch reflex gains were different in the two tested muscles.     

Effect of elbow joint angle on force–EMG relationships in human elbow flexor and extensor muscles

The purpose of this study was to examine the effect of joint angle on the relationship between force and electromyogram (EMG) amplitude and median frequency, in the biceps, brachioradialis and triceps muscles. Surface EMG were measured at eight elbow angles, during isometric flexion and extension at force levels from 10% to 100% of maximum voluntary contraction (MVC). Joint angle had a significant effect on MVC force, but not on MVC EMG amplitude in all of the muscles examined. The median frequency of the biceps and triceps EMG decreased with increasing muscle length, possibly due to relative changes in electrode position or a decrease in muscle fibre diameter. The relationship between EMG amplitude and force, normalised with respect to its maximum force at each angle, did not vary with joint angle in the biceps or brachioradialis muscles over all angles, or in the triceps between 45° and 120° of flexion. These results suggest that the neural excitation level to each muscle is determined by the required percentage of available force rather than the absolute force required. It is, therefore, recommended that when using surface EMG to estimate muscle excitation, force should be normalised with respect to its maximum value at each angle.     

Differences between motor unit firing rate, twitch characteristics and fibre type composition in an agonistic muscle group in man

A comparison was carried out between the motor unit (MU) firing rate and the characteristics of the twitch and the fibre type composition of anconeus and triceps brachii. Fibre type composition (type I, type II) was determined in whole cross-sections of cadaver specimens. The proportion of type I fibre was 60%-67% in anconeus and 32-40% in the lateral head of triceps brachii. Reflecting these histochemical differences, the contraction time of anconeus and triceps was 92 +/- 9 ms and 68 +/- 9 ms respectively. It follows that anconeus can be classified as a slow muscle, as opposed to the lateral head of triceps. The relationship between MU firing rate and isometric force, tested at 90 degrees elbow flexion, differed between the two muscles for force values below 30% of maximal voluntary contraction. No significant increase in MU firing rate was found in anconeus at forces above 5% of maximal voluntary contraction. It is concluded that even within a single agonistic muscle group acting at a single joint there is an adaptation of MU firing rate to the contractile characteristics of each muscle.     

EMG and MMG of agonist and antagonist muscles as a function of age and joint angle.

The aim of this study was to determine the effect of elbow joint position on electromyographic (EMG) and mechanomyographic (MMG) activities of agonist and antagonist muscles in young and old women. Surface EMG and MMG were recorded from the triceps and biceps brachii, and brachioradialis muscles during isometric elbow extensions in young and old women. The measurements were carried out at an optimal joint angle (A(o)), as well as at smaller (A(s) = A(o) - 30 degrees ) and larger (A(l) = A(o) + 30 degrees ) angles. The normalized to force EMG amplitude (RMS-EMG/F) was smaller in old women compared to young in all muscles. The RMS-EMG/F of the triceps brachii muscle was not affected by muscle length while that of the biceps brachii and brachioradialis muscles increased at shortest muscle length in both groups. The normalized to force MMG amplitude (RMS-MMG/F) was smaller in old than in young in the triceps brachii muscle only. There was an increase in RMS-MMG/F with triceps brachii and biceps brachii muscle shortening in both groups, and in the brachioradialis muscle -- in young only. Compared to young, older women exhibited a bigger force fluctuation during maximum voluntary contraction, but these did not contribute significantly to the RMS-MMG. Skinfold thickness accounted for the RMS-EMG/F and RMS-MMG/F differences seen between old and young women in the biceps brachii muscle only. It is concluded that, the EMG and MMG response to muscles length change in agonist and antagonist muscles is generally similar in old and young women but the optimal angle shifts toward a bigger value in older women.     

Effects of passive flexion of the forepaw on the response gain of limb extensors to sinusoidal stimulation of labyrinth receptors

The main aim of the present study was to find out whether the dynamic characteristics of responses of limb extensor muscles to labyrinth stimulation were modified by the proprioceptive input elicited by appropriate displacements of the corresponding limb extremity. In cats decerebrated at precollicular or intercollicular level, the multiunit EMG activity of the medial head of the triceps brachii was recorded during roll tilt of the animal at the frequency of 0.15 Hz, +/- 10 degrees leading to selective stimulation of labyrinth receptors. This stimulation was then tested several times at regular intervals of 2 to 6 min for several hours while maintaining the ipsilateral forelimb in the horizontal extended position, i.e. with the plantar surface of the foot lying on the tilting table, or during passive flexion of the forepaw in plantar or dorsal direction. In all the experiments in which the forelimb was in the control position, the multiunit EMG responses of the triceps brachii were characterized by an increased activity during side-down tilt of the animal and a decreased activity during side up tilt. These responses were related to animal position and not to the velocity of animal displacement, thus being attributed to stimulation of macular, utricular receptors. Static displacement of limb extremities following plantar flexion of the forepaw greatly decreased the amplitude of the EMG modulation and thus the gain of the first harmonic component of the multiunit EMG responses of the ipsilateral triceps brachii to animal tilt. This reduced gain was due not only to a reduced number of motor units recruited during labyrinth stimulation, but also to a reduced modulation of firing rate of the active motor units, as shown by recording the activity of individual motor units. On the other hand, displacement of the same extremity in the opposite direction, i.e. following dorsiflexion of the forepaw, enhanced the amplitude of the EMG modulation and thus the gain of the multiunit EMG responses of the ipsilateral triceps brachii to animal tilt. This finding was mainly due to an increased recruitment of motor units during side-down tilt, although an increased modulation of the firing rate of individual motor units could not be excluded. In both instances, no changes in the phase angle to the responses were observed. The changes in response gain described above depended on the amount of passive displacement of the forepaw and persisted unmodified throughout the new maintained position.(ABSTRACT TRUNCATED AT 400 WORDS)     

Mechanically induced reflex responses in human triceps brachii

The short and long latency reflex responses of human triceps brachii muscle were recorded in 14 healthy volunteers. An electromechanical hammer was used to stretch the muscle and recordings were made from a surface electromyogram. The monosynaptic tendon reflex occurred at a mean latency of 12.5 ms (SE 0.7 ms). Later responses were observed in activated conditions (weak force production, preparatory period) at a mean latency of 62.8 ms (SE 3.5 ms). The amplitude of the short latency reflex increased during weak tension, the long latency reflex amplitude seemed to increase during the preparatory period testing. The amplitude increases can be attributed to increased lower motoneuron excitability even during weak voluntary activity. The tendency towards an increased amplitude during the preparatory period may be connected with the higher regulation of the long latency reflex.     

Muscle activity patterns during quick increase of movement amplitude in rapid elbow extensions

In this study, we investigated a motor strategy for increasing the amplitude of movement in rapid extensions at the elbow joint. This study focused on the changes in a triphasic electromyographic (EMG) pattern, i.e., the first agonist burst (AG1), the second agonist burst (AG2) and the antagonist burst (ANT), for increasing the amplitude of movement required after the initiation of movement. Subjects performed 40° (Basic task) and 80° of extension (Wide task). These tasks were performed under two conditions; performing a predetermined task (SF condition) and performing a task in response to a visual stimulus immediately after movement commencement (ST condition). Kinematic parameters and EMG activity from the agonist (triceps brachii) and the antagonist (biceps brachii) muscles were recorded. As a result, the onset latency of AG1 and AG2 and the duration of AG1 were longer under the ST condition than the SF condition. No difference was observed between the SF and ST condition with respect to ANT activity. It is concluded that the motor strategy for increasing the amplitude of movement after the initiation of movement was to control the movement velocity and the timing to stop movement by the coactivation duration of AG1 and ANT and to stop the desired position accurately by AG2 activity.     

Effects of Local and Remote Muscle Pain on Stretch ReflexActivities in the Elbow Joint Flexors and Extensors of Unanesthetized Cats

In experiments on unanesthetized cats, we compared the effects of experimentally induced pain in the m. biceps brachii or in the neck muscles on EMG activity of the flexors and extensors of the elbow joint (mm. biceps et triceps brachii, respectively) evoked by a passive extension-flexion of the above joint. Muscle pain was induced by injections of 0.5 ml of a hypertonic (7%) NaCl solution into the above-mentioned muscles. In the case of pain in the biceps, i.e., in the muscle directly involved in realization of the reflex, we observed an increase in the amplitude and significant shortening of the latency of EMG responses of this muscle. The amplitude of a short-latency (supposedly monosynaptic) component of the biceps reflex (М1 response) increased by 65%, while an increment of the latter (supposedly polysynaptic) М2 component was 117%. When pain was induced in anatomically remote neck muscles, the stretch reflex in the biceps was considerably suppressed. The maximum amplitudes of the М1 and М2 components decreased by 25 and 30%, respectively, but the latencies of these components decreased significantly, similarly to what was observed in the case of induction of experimental pain in the biceps. Under both conditions of experimental pain, changes in the parameters of EMG responses of the forearm extensor (m. triceps brachii) demonstrated similarity with those of the biceps responses. The maximum effect of pain induction was observed within the first 5 min after injections of the hypertonic solution; full recovery of the stretch reflex parameters was observed on the 20th to 30th min. We conclude that the effects of pain induction on the reflex under study are not generalized. They depend on the site of such induction with respect to the muscle where the stretch reflex is elicited. Unidirectional effects of both types of pain on the antagonist muscles allow us to suppose that modulation of the reflex reactions upon pain induction is mediated by influences from the supraspinal CNS structures. Induction of pain in the biceps increased the amplitude of EMG manifestations of the stretch reflex, while such induction in the neck muscles decreased such responses; nonetheless, in both cases the latency of the reflexes decreased. This fact allows us to believe that the sensitivity of muscle spindles increased under both conditions of the pain influence.     

Effects of two days of isokinetic training on strength and electromyographic amplitude in the agonist and antagonist muscles

The purpose of this study was to examine the effects of 2 days of isokinetic training of the forearm flexors and extensors on strength and electromyographic (EMG) amplitude for the agonist and antagonist muscles. Seventeen men (mean +/- SD age = 21.9 +/- 2.8 years) were randomly assigned to 1 of 2 groups: (a) a training group (TRN; n = 8), or (b) a control group (CTL; n = 9). The subjects in the TRN group were tested for maximal isometric and concentric isokinetic (randomly ordered velocities of 60, 180, and 300 degrees x s(-1)) torque of the dominant forearm flexors and extensors before (pretest) and after (posttest) 2 days of isokinetic strength training. Each training session involved 6 sets of 10 maximal concentric isokinetic muscle actions of the forearm flexors and extensors at a velocity of 180 degrees x s(-1). The subjects in the CTL group were also tested for strength but did not perform any training. Surface EMG signals were detected from the biceps brachii and triceps brachii muscles during the strength testing. The results indicated that there were no significant (p > 0.05) pre- to post-test changes in forearm flexion and extension torque or EMG amplitude for the agonist and antagonist muscles. Thus, unlike previous studies of the quadriceps femoris muscles, these findings for the forearm flexors and extensors suggested that 2 days of isokinetic training may not be sufficient to elicit significant increases in strength. These results may have implications for the number of visits that are required for rehabilitation after injury, surgery, or both.     

EMG and MMG activities of agonist and antagonist muscles in Parkinson’s disease patients during absolute submaximal load holding

The purpose of the study was (1) to assess changes in electromyographical (EMG) and mechanomyographical (MMG) signals of the biceps and triceps brachii muscles during absolute submaximal load holding in Parkinson’s disease patients tested during their medication “ON-phase” and in age-matched controls, and (2) to check whether mechanomyography can be useful in evaluation of neuromuscular system activity in Parkinson’s disease patients.The data analysis was performed on nine females with Parkinson’s disease and six healthy, age-matched females. The EMG and MMG signals were recorded from the short head of the biceps brachii (BB) and the lateral head of the triceps brachii (TB) muscles.It was concluded that compared to the controls, the Parkinson’s disease patients exhibited higher amplitude in the biceps brachii muscle and lower median frequency of the MMG signal in the both tested muscles. However, no differences in the EMG amplitude and an increase of the EMG median frequency in the triceps brachii muscle of the Parkinson’s disease group were observed. The MMG was not affected by physiological postural tremor and can depict differences between parkinsonians and controls, which may suggest that it is valuable tool for neuromuscular assessment for this condition.     

Limiting mechanisms of force production after repetitive dynamic contractions in human triceps surae.

The influence of repetitive dynamic fatiguing contractions on the neuromuscular characteristics of the human triceps surae was investigated in 10 subjects. The load was 50% of the torque produced during a maximal voluntary contraction, and the exercise ended when the ankle range of motion declined to 50% of control. The maximal torque of the triceps surae and the electromyographic (EMG) activities of the soleus and medial gastrocnemius were studied in response to voluntary and electrically induced contractions before and after the fatiguing task and after 5 min of recovery. Reflex activities were also tested by recording the Hoffmann reflex (H reflex) and tendon reflex (T reflex) in the soleus muscle. The results indicated that whereas the maximal voluntary contraction torque, tested in isometric conditions, was reduced to a greater extent (P < 0.05) at 20 degrees of plantar flexion (-33%) compared with the neutral position (-23%) of the ankle joint, the EMG activity of both muscles was not significantly reduced after fatigue. Muscle activation, tested by the interpolated-twitch method or the ratio of the voluntary EMG to the amplitude of the muscle action potential (M-wave), as well as the neuromuscular transmission and sarcolemmal excitation, tested by the M-wave amplitude, did not change significantly after the fatiguing exercise. Although the H and T reflexes declined slightly (10-13%; P < 0.05) after fatigue, these adjustments did not appear to have a direct deleterious effect on muscle activation. In contrast, alterations in the mechanical twitch time course and postactivation potentiation indicated that intracellular Ca(2+)-controlled excitation-contraction coupling processes most likely played a major role in the force decrease after dynamic fatiguing contractions performed for short duration.     

Comparison of muscle activation using various hand positions during the push-up exercise

Popular fitness literature suggests that varied hand placements during push-ups may isolate different muscles. Scientific literature, however, offers scant evidence that varied hand placements elicit different muscle responses. This study examined whether different levels of electromyographic (EMG) activity in the pectoralis major and triceps brachii muscles are required to perform push-ups from each of 3 different hand positions: shoulder width base, wide base, and narrow base hand placements. Forty subjects, 11 men and 29 women, performed 1 repetition of each push-up. The EMG activity for subjects' dominant arm pectoralis major and triceps brachii was recorded using surface electrodes. The EMG activity was greater in both muscle groups during push-ups performed from the narrow base hand position compared with the wide base position (p < 0.05). This study suggests that, if a goal is to induce greater muscle activation during exercise, then push-ups should be performed with hands in a narrow base position compared with a wide base position.     

A motion of forearm supination with maintenance of elbow flexion produced by electrical stimulation to two elbow flexors in humans.

Motions of the forearm induced by electrical stimulation to two elbow flexors (brachioradialis: BR, biceps brachii: BB) were examined in five healthy human subjects. Stainless steel wire electrodes were implanted percutaneously into each motor point of the muscles. The muscles were stimulated separately with a computer-controlled multi-channel stimulator. The motions were taken with a digital video system. Angular changes of the motions in elbow flexion/extension and forearm pronation/supination were measured. Electromyograms (EMG) of BR, BB, and the triceps brachii (TB) were recorded. Electrical stimulation to BR induced a motion of flexion and that to BB motions of flexion and supination. The stimulation to BR with an adequate intensity provided holding of flexion with the prone forearm in all the subjects. In this situation, additional stimulation to BB resulted in motions of flexion and supination. However, the additional stimulation accompanied with a decrease of the stimulation intensity for BR provided a motion of supination with maintenance of the flexion in all the subjects. Since during the stimulation BR, BB, and TB showed no voluntary contraction in EMG, it is suggested that modulation of contraction between BR and BB by the stimulation can produce force in supination with keeping constant force in flexion to support the weight below the elbow.     

Changes in kinematic and EMG variability while practicing a maximal performance task.

This paper examines changes in the variability of electromyographic (EMG) activity and kinematics as a result of practicing a maximal performance task. Eight subjects performed rapid elbow flexion to a target in the horizontal plane. Four hundred trials were distributed equally over four practice sessions. A potentiometer at the elbow axis of rotation of a manipulandum recorded the angular displacement. The EMG activity of the biceps and the triceps brachii was monitored using Beckman surface electrodes. Limb speed increased while both target error and trajectory (velocity versus position) variability decreased. There was an increase in the absolute measure of total EMG variability (the first standard deviation at each point of the biceps and triceps waveform multiplied together). However, the coefficient of variation (the first standard deviation divided by the mean and the result multiplied by 100) of the mean amplitude value of the individual EMG bursts decreased. The variability of triceps motor time also decreased while the variability biceps motor time remained unchanged. The results demonstrated a clear relationship between kinematic and EMG variability. The EMG and the trajectory data suggest that practice resulted in greater central nervous system control over both the spatial-temporal aspects of movement and the magnitude of the biceps and triceps muscle force-impulses.     

The fatigability of two agonistic muscles in human isometric voluntary submaximal contraction: an EMG study I. Assessment of muscular fatigue by means of surface EMG

During an external isometric constant torque (25% of the maximal voluntary contraction) maintained until the maximal endurance time (limit time), we analysed and compared the changes in electromyographic (EMG) activity illustrating muscular fatigue simultaneously with mechanical activity (the tangential acceleration theta") related to physiological tremor. The EMG activities recorded were of two agonistic flexors, the biceps brachii (BB) and the brachioradialis (BR) muscles and one of the main extensors, the triceps brachii (TB). The integrated EMG increase and the mean power frequency (MPF) of the power spectrum density function (PSDF) decrease were larger for BR than for BB activity. These two findings suggested a greater BR fatigability. However, it is shown that differences between BB and BR MPF changes could be related to differences in the PSDF upper frequency limit of the two muscles and also to the relative magnitude of their tremor component.     

Velocity-dependent muscle strategy during plantarflexion in humans

This work examines the relative contribution of the triceps surae heads and the tibialis anterior (TA) to tension development with reference to voluntary plantarflexion at various velocities and at two articular positions of the knee joint (extended and flexed at 90 °). Subjects were instructed to perform plantarflexion at various submaximal and maximal velocities with no intention of stopping the movement. Voluntary electromyographic (EMG) activity was recorded and the amplitude, duration and integral were analysed. Integrated EMG (IEMG) was normalized with respect to duration. The maximal M wave and the Hoffmann (H) reflex elicited by electrical stimulation of the tibial nerve were recorded in the triceps surae to estimate the effects in gastrocnemii (G) length and motoneuron excitability differences, respectively, in the two knee positions. The results indicate that: (a) although the largest EMG activity was recorded in the extended limb, the greatest maximal velocities were performed in the flexed knee position; (b) with increasing velocity of movement, all triceps surae muscles showed enhanced IEMG activities; (c) at a low velocity of movement the soleus (So1)/G IEMG ratio was larger in the flexed compared to the extended knee; and (d) with increasing velocity, co-activation of agonist and antagonist muscles appeared. It is concluded that the larger maximal velocity of movement observed in the flexed compared to the extended knee was not primarily related to the neural command of the different triceps surae components, but rather to their mechanical properties. Furthermore, co-activation of agonist and antagonist muscles may contribute to the performance of the contractile strategy during rapid movements.     

The effect of handgrip position on upper extremity neuromuscular responses to arm cranking exercise.

The purpose of this study was to determine if handgrip position during arm cranking exercise influences the neuromuscular activity of muscles biceps brachii (BB), lateral head of triceps brachii (TB), middle deltoid (DT), infraspinatus (IS) and brachioradialis (BR). Fifteen participants cranked an arm ergometer using three different handgrip positions (supinated, pronated, and neutral). Electromyographic (EMG) data were recorded from the aforementioned muscles, and relative duration of EMG activation and amplitude were quantified for the first and second 180 degrees of crank angle. EMG measures were analyzed with MANOVA and follow-up univariate procedures; alpha was set at 0.01. The relative durations of EMG activation did not differ between handgrip positions. Muscle IS exhibited 36% less amplitude in the supinated versus neutral handgrip position (second half-cycle), and muscle BR displayed 63% greater amplitude across cycles in the neutral versus supinated and pronated handgrip positions. The greater BR activity displayed in the neutral handgrip position may reflect its anatomical advantage as an elbow flexor when the forearm is in neutral position. Muscle IS exhibited less activity in the supinated position and may be clinically relevant if it allows arm cranking to occur without subsequent shoulder pain, which is often the aim of shoulder rehabilitation.     

The role of co-activation in strength and force modulation in the elbow of children with unilateral cerebral palsy

To study the role of coactivation in strength and force modulation in the elbow joint of children and adolescents with cerebral palsy (CP), we investigated the affected and contralateral arm of 21 persons (age 8-18) with spastic unilateral CP in three tasks: maximal voluntary isokinetic concentric contraction and passive isokinetic movement during elbow flexion and extension, and sub-maximal isometric force tracing during elbow flexion. Elbow flexion-extension torque and surface electromyography (EMG) of the biceps brachii (BB) and triceps brachii (TB) muscles were recorded. During the maximal contractions, the affected arm was weaker, had decreased agonist and similar antagonist EMG amplitudes, and thus increased antagonist co-activation (% of maximal activity as agonist) during both elbow flexion and extension, with higher coactivation levels of the TB than the BB. During passive elbow extension, the BB of the affected arm showed increased resistance torque and indication of reflex, and thus spastic, activity. No difference between the two arms was found in the ability to modulate force, despite increased TB coactivation in the affected arm. The results indicate that coactivation plays a minor role in muscle weakness in CP, and does not limit force modulation. Moreover, spasticity seems particularly to increase coactivation in the muscle antagonistic to the spastic one, possibly in order to increase stability.     

Elbow extensor muscles of the horse: postural and dynamic implications.

Based on histochemical and immunohistochemical evidence, horse elbow extensor muscles are composed of two morphologically distinct muscle groups. The long and lateral heads of the triceps brachii are large, predominantly type II (presumed fast) muscles. The long and lateral heads of the triceps together account for 96% of the weight of the elbow extensors (long head of triceps is 81%). The long and lateral heads contain three histochemical fiber types: types I, IIa and IIb. Type I muscle fibers account for approximately 18 and 27% of the fibers in the long and lateral heads of the triceps, respectively. In the lateral head, type IIa and IIb fibers account equally for the remaining 70%, while in the long head of the triceps type IIb fibers predominate (50%) over type IIa fibers (32%). In contrast, the much smaller medial head of the triceps (2% of triceps mass) and the anconeus (2% of mass) contain almost exclusively type I muscle fibers. It is hypothesized that the medial head and anconeus, with their slow fibers, contribute to the postural maintenance of the forelimb by preventing flexion at the elbow joint during passive stance. The larger long and lateral heads, with their generally fast fiber populations, are most likely important during dynamic activity.     

Reflex muscle contractions can be elicited by valgus positional perturbations of the human knee

Experimental evidence on the reflex responses of thigh muscles to valgus mechanical perturbations at the human knee are presented. Random step positional deflections, ranging from 5 degrees to 12 degrees at 60 degrees /s, were applied to the fully extended knees of seven healthy subjects. Subjects were instructed to maintain a constant background co-activation ( approximately 2-11% MVC) of the quadriceps and hamstring muscles prior to and during the mechanical stimulus. We found that the reflex response to sustained valgus joint deflection in the vasti muscles had longer onset latencies (range: 83-92ms) than did the stretch reflex in the same muscles (latencies: 29-31ms). This reflex EMG response consisted typically of a peak followed by sustained muscle activity throughout the step perturbation. The sustained EMG activity was dependent on the amplitude of the perturbing stimulus, but in a nonlinear manner. The long latency of the valgus response suggests that the reflex originates in nonmuscular sensory pathways, potentially from mechanoreceptors lying in periarticular tissues such as joint ligaments and capsule. Analysis of the spatial distribution of reflex responses showed an asymmetrical pattern with preferential activation of medial vs. lateral muscles of the knee. We assess whether these asymmetric reflex contractions could promote joint stability, either by inducing generalized joint stiffening, or by preferential activation of those muscles that are best suited to resist induced ligament strain.