For individuals who have decided to start exercising for fitness and health, walking is a great place to start. Can planning a walking exercise schedule help individuals maintain a fitness routine and improve endurance and speed quicker?
Walking Exercise Planning Schedule
While any amount of walking benefits health, individuals can increase the benefits by walking more per week or by increasing the pace. Brisk walking for 30 minutes per day, totaling 150 minutes per week, is recommended by health experts to decrease risks for heart disease, stroke, diabetes, and other conditions. (Centers for Disease Control and Prevention. 2022)
Individuals with ongoing health conditions should talk to their doctor before starting any new exercise program.
Beginners are encouraged to focus on using proper walking posture and technique to steadily improve strength and endurance.
The increased duration or intensity can help if weight loss is a goal.
Improving diet is also necessary for the best results.
Individuals can build healthy walking habits by tracking walks.
Schedule
Checklist
Individuals can walk outdoors, indoors, or on a treadmill.
Wear proper athletic shoes and clothing.
Check walking posture.
Walk at an easy pace for a couple of minutes before picking up speed.
First Week
An example of what a walking exercise schedule can look like, but it’s advised to consult a professional trainer to develop a personalized fitness plan.
Start with a 15-minute walk at an easy pace.
Walk five days the first week.
Building a healthy habit is the goal, so consistency is important.
Spread out rest days, like making days 3 and 6 rest days.
Weekly goal – 60 to 75 minutes
Second Week
Add five minutes, so the walk time increases gradually.
Or, individuals can extend more on some days, followed by a rest day.
Weekly goal – 80 to 100 minutes
Third Week
Add five more minutes with each session, so the walk increases to 25 minutes.
Weekly goal – 100 to 125 minutes
Fourth Week
Add another five minutes to increase the walk to 30 minutes.
Weekly goal – 120 to 150 minutes
Individuals who find any week to be difficult are suggested to repeat that week instead of adding time until they are able to progress naturally. Once able to walk for 30 minutes at a time comfortably, individuals are ready for a variety of different walking exercise workouts to add intensity and endurance. A weekly walking plan can include:
Longer walks
Higher-intensity walks
Speed-building walks
Beginner Walking Speed
An individual’s objective should be brisk walking to achieve a moderate-intensity workout. This is the intensity that is associated with the most health benefits.
If the speed is slower and the heart rate is lower during the initial weeks, this is normal.
The first goal is to walk for 30 to 60 minutes a day without injury.
Adding speed and intensity gradually.
Staying consistent in regularly walking before trying to walk faster and longer.
Using proper walking posture and arm motion will help in faster walking.
To reduce the risk of injury, gradually increase the length of the walk or pace, only changing one component at a time.
Individuals may consider joining a walking group or club to have others to walk with and an incentive to maintain regular walking.
Home Exercises for Pain Relief
References
Centers for Disease Control and Prevention. (2022). How Much Physical Activity Do Adults Need? Retrieved from https://www.cdc.gov/physicalactivity/basics/adults/index.htm
Centers for Disease Control and Prevention. (2022). Measuring Physical Activity Intensity. Retrieved from https://www.cdc.gov/physicalactivity/basics/measuring/index.html
Centers for Disease Control and Prevention. (2022). Target Heart Rate and Estimated Maximum Heart Rate. Retrieved from https://www.cdc.gov/physicalactivity/basics/measuring/heartrate.htm
Mahmod, S. R., Narayanan, L. T., & Supriyanto, E. (2018). Effects of incremental cardiorespiratory exercise on the speech rate and the estimated exercise intensity using the counting talk test. Journal of physical therapy science, 30(7), 933–937. https://doi.org/10.1589/jpts.30.933
During a fall individuals tend to automatically outstretch their hands to help break a fall, which can slam onto the ground causing a falling onto an outstretched hand or FOOSH injury. Should individuals get checked by a healthcare provider if they believe there is no injury?
FOOSH Injuries
Falling down usually results in minor injuries. A FOOSH injury occurs when falling down and trying to break the fall by reaching out with the hand/s. This can result in an upper extremity injury like a sprain or a fracture. But sometimes, falling on one’s hands can lead to serious injuries and/or create future musculoskeletal issues. Individuals who have fallen or suffered a FOOSH injury should consult their healthcare provider and then a physical therapist or chiropractor to safely develop a treatment plan to rehabilitate, strengthen, and expedite recovery.
After The Injury
For individuals who have fallen down and landed on their hand, wrist, or arm, here are a few things to ensure the proper care for the injury, including:
Follow the R.I.C.E. protocol for acute injuries
Visit a healthcare provider or local emergency clinic
Contact a physical therapist
A FOOSH injury could be or become serious, so to avoid letting small issues become big problems, get examined by a musculoskeletal specialist. The healthcare provider will obtain an imaging scan of the injured and surrounding areas. They will perform a physical examination to determine the type of injury, like a sprain or muscle strain. Not getting appropriate medical treatment after a fall can result in chronic pain and loss of function. (J. Chiu, S. N. Robinovitch. 1998)
Common Injuries
A FOOSH injury can injure different areas. These usually involve the wrist and hand, but the elbow or shoulder can also be injured. Common injuries include:
Colles’ fracture
A wrist fracture where the end of the arm bone is displaced backward.
Smith’s fracture
A wrist fracture, similar to a Colles’ fracture, is where the end of the arm bone is displaced towards the front of the wrist.
Boxer’s fracture
A fracture of the small bones in the hand.
Typically, it occurs after punching something, but it can happen from falling on an outstretched fist.
Elbow dislocation or fracture
The elbow can pop out of the joint or can break a bone in the elbow.
Collarbone fracture
The force from falling with the hands and arms outstretched can travel up to the collarbone, causing a fracture.
Proximal humeral fracture
Falling onto an outstretched hand injury can cause the arm bone to get jammed into the shoulder, causing a proximal humeral fracture.
Shoulder dislocation
The shoulder can pop out of the joint.
This can cause a rotator cuff tear or labrum injury.
Regardless of the injury, individuals should visit a healthcare provider to evaluate the damage. If the injury is serious, the practitioner can make an accurate or differential diagnosis and develop a treatment plan. (William R. VanWye et al., 2016)
Physical Therapy
Individuals can benefit from physical therapy to help recover and return to their previous level of function. Physical therapy varies depending on the specific injury, but generally, a physical therapist can help individuals return to function after a fall on an outstretched hand. (William R. VanWye et al., 2016) Common treatments can include:
Treatments and modalities to decrease pain, inflammation, and swelling.
Instruction on how to wear an arm sling properly.
Exercises and stretches to improve the range of motion, strength, and functional mobility.
Balance exercises.
Scar tissue management if surgery was necessary.
The therapy team will ensure the proper treatment is utilized to quickly and safely return to normal activities.
Chiropractic Care For Healing After Trauma
References
Chiu, J., & Robinovitch, S. N. (1998). Prediction of upper extremity impact forces during falls on the outstretched hand. Journal of biomechanics, 31(12), 1169–1176. https://doi.org/10.1016/s0021-9290(98)00137-7
VanWye, W. R., Hoover, D. L., & Willgruber, S. (2016). Physical therapist screening and differential diagnosis for traumatic-onset elbow pain: A case report. Physiotherapy theory and practice, 32(7), 556–565. https://doi.org/10.1080/09593985.2016.1219798
Individuals who participate in physical and sports activities could suffer an Achilles tendon tear. Can understanding the symptoms and risks help in treatment and return the individual back to their sports activity sooner?
Achilles Tendon
This is a common injury that occurs when the tendon attaching the calf muscle to the heel gets torn.
About the Tendon
The Achilles tendon is the largest tendon in the body.
In sports and physical activities, intense explosive movements like running, sprinting, quickly shifting positions, and jumping are exerted on the Achilles.
The injury often occurs without any contact or collision but rather the running, starting, stopping, and pulling actions placed on the feet.
Certain antibiotics and cortisone shots can increase the likelihood of Achilles tear injuries.
A specific antibiotic, fluoroquinolones, has been shown to increase the risk of Achilles tendon problems.
Cortisone shots are also associated with Achilles tears, which is why many healthcare providers don’t recommend cortisone for Achilles tendonitis. (Anne L. Stephenson et al., 2013)
Symptoms
A tendon tear or rupture causes sudden pain behind the ankle.
Individuals may hear a pop or a snap and often report the feeling as being kicked in the calf or heel.
Individuals have difficulty pointing their toes downward.
Individuals may have swelling and bruising around the tendon.
A healthcare provider will examine the ankle for continuity of the tendon.
Squeezing the calf muscle is supposed to cause the foot to point downwards, but in individuals with a tear, the foot will not move, resulting in positive results on the Thompson test.
A defect in the tendon can usually be felt after a tear.
X-rays may be used to rule out other conditions, including ankle fracture or ankle arthritis.
Fluoroquinolone antibiotics are commonly used for the treatment of respiratory infections, urinary tract infections, and bacterial infections. These antibiotics are associated with Achilles tendon rupture, but further research is needed to determine how they affect the Achilles tendon. Individuals taking these medications are advised to consider an alternative medication if Achilles tendon problems begin to develop. (Anne L. Stephenson et al., 2013)
Treatment
Depending on the severity of the injury, treatment can consist of non-surgical techniques or surgery.
The benefit of surgery is there is usually less immobilization.
Individuals can often return to sports activities sooner, and there is less chance of re-rupturing the tendon.
Thevendran, G., Sarraf, K. M., Patel, N. K., Sadri, A., & Rosenfeld, P. (2013). The ruptured Achilles tendon: a current overview from biology of rupture to treatment. Musculoskeletal surgery, 97(1), 9–20. https://doi.org/10.1007/s12306-013-0251-6
Stephenson, A. L., Wu, W., Cortes, D., & Rochon, P. A. (2013). Tendon Injury and Fluoroquinolone Use: A Systematic Review. Drug safety, 36(9), 709–721. https://doi.org/10.1007/s40264-013-0089-8
Pedowitz, D., & Kirwan, G. (2013). Achilles tendon ruptures. Current reviews in musculoskeletal medicine, 6(4), 285–293. https://doi.org/10.1007/s12178-013-9185-8
Yasui, Y., Tonogai, I., Rosenbaum, A. J., Shimozono, Y., Kawano, H., & Kennedy, J. G. (2017). The Risk of Achilles Tendon Rupture in the Patients with Achilles Tendinopathy: Healthcare Database Analysis in the United States. BioMed research international, 2017, 7021862. https://doi.org/10.1155/2017/7021862
Individuals that engage in heavy exercise can develop heat cramps from overexertion. Can knowing the causes and symptoms help prevent future episodes from happening?
Heat Cramps
Heat cramps can develop during exercise from overexertion or prolonged exposure to high temperatures. The muscle cramps, spasms, and pain can range from mild to severe.
Electrolytes like sodium, calcium, and magnesium are important for properly functioning muscles, including the heart. The primary role of sweating is to regulate the body’s temperature. (MedlinePlus. 2015) Sweat is mostly water, electrolytes, and sodium. Excessive sweating from physical activity and exertion or a hot environment can cause electrolyte imbalances that lead to cramps, spasms, and other symptoms.
Causes and Activities
Heat cramps most commonly affect individuals who sweat excessively during strenuous activity or are exposed to hot temperatures for prolonged periods. The body and organs need to cool down, which causes sweat production. However, too much sweating can lead to dehydration and electrolyte depletion. (Centers for Disease Control and Prevention. 2022)
Age – Children and adults 65 years and older have the highest risk.
Excessive sweating.
Low sodium diet.
Preexisting Medical Conditions – heart disease, diabetes mellitus, and obesity are conditions that can increase the risk of muscle cramping.
Medications – blood pressure, diuretics, and antidepressants can affect electrolyte balance and hydration.
Alcohol consumption.
Self-Care
If heat cramps begin, immediately stop the activity and look for a cool environment. Rehydrate the body to replenish the fluid loss. Staying hydrated and drinking fluids regularly during intense activity or in a hot environment can help prevent the body from cramping. examples of beverages that increase electrolytes include:
Gently applying pressure and massaging affected muscles can help reduce pain and spasms. As symptoms resolve, it is recommended to not return to strenuous activity too soon because additional exertion can progressively lead to heatstroke or heat exhaustion. (Centers for Disease Control and Prevention. 2021) Heatstroke and heat exhaustion are two heat-related illnesses. (Centers for Disease Control and Prevention. 2022)
Heatstroke is when the body loses the ability to regulate temperature and can cause dangerously high temperatures.
Heat exhaustion is the body’s response to excessive fluid and electrolyte loss.
The majority of heat cramps develop during activities because of the exertion and sweating, causing more electrolytes to be lost and the body to become more dehydrated.
Symptoms can also develop minutes to hours after activity has ceased.
Duration
Most heat-related muscle cramps will resolve with rest and hydration within 30–60 minutes.
If muscle cramping or spasms do not subside within one hour, seek professional medical attention.
For individuals with heart conditions or on a low-sodium diet who develop heat cramps, regardless of duration, medical help is necessary to ensure there are no complications.
Drink plenty of fluids before and during physical activities.
Avoid alcohol and caffeinated beverages.
Avoid exercising or exposure to extreme heat during peak sunlight hours.
Avoid tight and dark-colored clothing.
Assessing Patients In A Chiropractic Setting
References
Gauer, R., & Meyers, B. K. (2019). Heat-Related Illnesses. American family physician, 99(8), 482–489.
Centers for Disease Control and Prevention. (2022). Heat stress — heat related illness. The National Institute for Occupational Safety and Health (NIOSH) Retrieved from https://www.cdc.gov/niosh/topics/heatstress/heatrelillness.html#cramps
MedlinePlus. (2015). Sweat. Retrieved from https://medlineplus.gov/sweat.html#cat_47
FoodData Central. (2019). Nuts, coconut water (liquid from coconuts). Retrieved from https://fdc.nal.usda.gov/fdc-app.html#/food-details/170174/nutrients
FoodData Central. (2019). Milk, nonfat, fluid, with added vitamin A and vitamin D (fat free or skim). Retrieved from https://fdc.nal.usda.gov/fdc-app.html#/food-details/746776/nutrients
Centers for Disease Control and Prevention. (2012). Frequently asked questions (FAQ) about extreme heat. Retrieved from https://www.cdc.gov/disasters/extremeheat/faq.html
For individuals trying to maintain a healthy spine, can understanding the causes and prevention of rotated vertebrae help protect the spine from harmful rotation of vertebrae?
Spinal Rotation
Healthy spine rotation is an important aspect of injury prevention, and rotated vertebrae or a twisted spine can result from spine, nerve, or muscle disease or certain movements.
Normal Spine Twisting Capability
The spine can move in several ways. Spine movements include:
Bending – Rounding forward
Extending – Arching backward
Tilting sideways is powered by muscles that aid in twisting.
Although the spine can move in many directions, there are limits to how far it can and should go. (Xinhai Shan et al., 2013). This is especially true with twisting. The spinal column is made of 26 interconnected bones called vertebrae. When moving, each vertebrae bone moves accordingly. Rotated or twisted vertebrae, especially when bending forward like lifting heavy objects, are associated with a risk of back injuries like strain and herniated discs.
How Rotation Works
Rotation is a basic movement in which individuals can turn their spinal column. When twisting, the spine also bends to the side. The muscles involved in spine rotation include:
The internal oblique abdominals and the external oblique abdominals don’t directly attach to the spine but are the primary muscles responsible for powering spinal rotation in the lower back.
Intrinsic muscles, including the multifidus and longissimus, contribute to twisting movement as well.
The multifidus helps the spine twist when one side is contracted/activated and extends the lumbar spine when both sides contract.
The multifidus helps control the movement, and the longissimus provides the movement with some extension.
Age and The Spine
As individuals age, the body accumulates tension and/or weakness in the oblique abdominal and other trunk muscles. Sedentary habits primarily bring on these changes. (Pooriput Waongenngarm et al., 2016)
Chronically tight back and abdominal muscles impair the range of motion of the trunk, as well as twisting ability.
Muscle weakness and tightness affect spinal movements.
Weakened muscles can decrease support for spinal movement and decrease overall trunk stability.
Spinal Rotation and Scoliosis
Scoliosis is a common condition that causes a lateral curve of the spine. Some of the vertebrae become displaced to the side. Often, abnormal vertebral rotation underlies this displacement. Treatment often focuses on controlling vertebral rotation with medical guidance and physical therapy. (John P. Horne et al., 2014)
Over-Rotating The Spine
Many individuals over-rotate their spines with manual work, which can increase the risk of back injuries. (National Institutes of Health. 2020). Over-rotation can happen with activities like digging or shoveling.
Exercise For A Healthy Spine
A recommended way to achieve optimal rotation of the spine is with daily back exercises. (National Spine Health Foundation. 2015). An effective back exercise program will consist of movements in every direction.
Yoga is recommended because it places emphasis on developing flexibility and strength in all directions.
Pilates does the same.
An injury prevention exercise program will work the hip and pelvic muscles as well.
Individuals with a spine condition should consult their healthcare provider or physical therapist about how to exercise the spine safely, as rotation exercises could worsen back problems like bulging or herniated discs.
Core Strength For A Pain-Free Back
References
Shan, X., Ning, X., Chen, Z., Ding, M., Shi, W., & Yang, S. (2013). Low back pain development response to sustained trunk axial twisting. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 22(9), 1972–1978. https://doi.org/10.1007/s00586-013-2784-7
Waongenngarm, P., Rajaratnam, B. S., & Janwantanakul, P. (2016). Internal Oblique and Transversus Abdominis Muscle Fatigue Induced by Slumped Sitting Posture after 1 Hour of Sitting in Office Workers. Safety and health at work, 7(1), 49–54. https://doi.org/10.1016/j.shaw.2015.08.001
Individuals may not realize they have a cracked rib until symptoms like pain when taking in a deep breath begin to present. Can knowing the symptoms and causes of cracked or broken ribs help in diagnosis and treatment?
Cracked Rib
A broken/fractured rib describes any break in the bone. A cracked rib is a type of rib fracture and is more a description than a medical diagnosis of a rib that has been partially fractured. Any blunt impact to the chest or back can cause a cracked rib, including:
Falling
Vehicle collision
Sports injury
Violent coughing
The main symptom is pain when inhaling.
The injury typically heals within six weeks.
Symptoms
Cracked ribs are usually caused by a fall, trauma to the chest, or intense violent coughing. Symptoms include:
Swelling or tenderness around the injured area.
Chest pain when breathing/inhaling, sneezing, laughing, or coughing.
Chest pain with movement or when lying down in certain positions.
Possible bruising.
Although rare, a cracked rib can cause complications like pneumonia.
See a healthcare provider immediately if experiencing difficulty breathing, severe chest pain, or a persistent cough with mucus, high fever, and/or chills.
Types
In most cases, a rib usually gets broken in one area, causing an incomplete fracture, which means a crack or break that does not go through the bone. Other types of rib fractures include:
Displaced and Nondisplaced Fractures
Completely broken ribs may or may not shift out of place.
If the rib does move, this is known as a displaced rib fracture and is more likely to puncture lungs or damage other tissues and organs. (Yale Medicine. 2024)
A rib that stays in place usually means the rib is not completely broken in half and is known as a nondisplaced rib fracture.
Flail Chest
A section of the ribcage can break away from the surrounding bone and muscle, although this is rare.
If this happens, the ribcage will lose stability, and the bone will move freely as the individual inhales or exhales.
This broken ribcage section is called a flail segment.
This is dangerous as it can puncture the lungs and cause other serious complications, like pneumonia.
Causes
Common causes of cracked ribs include:
Vehicle collisions
Pedestrian accidents
Falls
Impact injuries from sports
Overuse/Repetitive stress brought on by work or sports
Severe coughing
Older individuals can experience a fracture from a minor injury due to the progressive loss of bone minerals. (Christian Liebsch et al., 2019)
The Commonality of Rib Fractures
Rib fractures are the most common type of bone fracture.
They account for 10% to 20% of all blunt trauma injuries seen in emergency rooms.
In cases where an individual seeks care for a blunt injury to the chest, 60% to 80% involve a broken rib. (Christian Liebsch et al., 2019)
Diagnosis
A cracked rib is diagnosed with a physical exam and imaging tests. During the examination, a healthcare provider will listen to the lungs, press gently on the ribs, and watch as the rib cage moves. The imaging test options include: (Sarah Majercik, Fredric M. Pieracci 2017)
X-rays – These are for detecting recently cracked or broken ribs.
CT Scan – This imaging test comprises multiple X-rays and can detect smaller cracks.
MRI – This imaging test is for soft tissues and can often detect smaller breaks or cartilage damage.
Bone Scan – This imaging test uses a radioactive tracer to visualize the structure of bones and can show smaller stress fractures.
Treatment
In the past, treatment used to involve wrapping the chest with a band known as a rib belt. These are rarely used today as they can restrict breathing, increasing the risk of pneumonia or even a partial lung collapse. (L. May, C. Hillermann, S. Patil 2016). A cracked rib is a simple fracture that requires the following:
Rest
Over-the-counter or prescription medications can help manage pain symptoms.
Nonsteroidal anti-inflammatory drugs – NSAIDs like ibuprofen or naproxen are recommended.
If the break is extensive, individuals may be prescribed stronger pain medication depending on the severity and underlying conditions.
Physical therapy can expedite the healing process and help maintain the range of motion of the chest wall.
For patients who are frail and elderly individuals, physical therapy can help the patient walk and normalize certain functions.
A physical therapist can train the individual to transfer between bed and chairs safely while maintaining awareness of any movements or positioning that make the pain worse.
A physical therapist will prescribe exercises to keep the body as strong and limber as possible.
For example, lateral twists can help improve the range of motion in the thoracic spine.
During the early stages of recovery, it is recommended to sleep in an upright position.
Lying down can add pressure, causing pain and possibly worsen the injury.
Use pillows and bolsters to help support sitting up in bed.
What may feel like a cracked rib may be a similar condition, which is why it’s important to get checked out. Other possible symptom causes can include:
Bruised ribs – This occurs when the ribs are not cracked, but the smaller blood vessels around the region burst and leak into surrounding tissues. (Sarah Majercik, Fredric M. Pieracci 2017)
Pulled muscle – A muscle strain, or pulled muscle, occurs when the muscle gets overstretched, which can lead to a tear. The ribs are not affected, but it can feel like they are. (Sarah Majercik, Fredric M. Pieracci 2017)
Emergency
The most common complication is being unable to take a deep breath because of the pain. When the lungs cannot breathe deeply enough, mucous and moisture can build up and lead to an infection like pneumonia. (L. May, C. Hillermann, S. Patil 2016). Displaced rib fractures can also damage other tissues or organs, increasing the risk of a collapsed lung/pneumothorax or internal bleeding. It is recommended to seek immediate medical attention if symptoms develop like:
Shortness of breath
Difficulty breathing
A bluish color of the skin caused by lack of oxygen
A persistent cough with mucus
Chest pain when breathing in and out
Fever, sweating, and chills
Rapid heart rate
The Power of Chiropractic Care In Injury Rehabilitation
Liebsch, C., Seiffert, T., Vlcek, M., Beer, M., Huber-Lang, M., & Wilke, H. J. (2019). Patterns of serial rib fractures after blunt chest trauma: An analysis of 380 cases. PloS one, 14(12), e0224105. https://doi.org/10.1371/journal.pone.0224105
A dislocated elbow is a common injury in adults and children and often happens in tandem with bone fractures and nerve and tissue damage. Can physical therapy help to support recovery and ensure range of motion?
Dislocated Elbow Injury
Elbow dislocations are generally caused by trauma when the elbow bones no longer connect. Individuals falling onto an outstretched hand is the most common cause of the injury. (James Layson, Ben J. Best 2023) Healthcare providers will try to relocate the elbow using a closed reduction. Individuals may require surgery if they cannot relocate the elbow using closed reduction.
The hinge function allows the bending and straightening of the arm.
Ball-and-socket joint
The ball-and-socket function allows you to rotate the palm of your hand to face up or face down.
A dislocated elbow injury can damage bones, muscles, ligaments, and tissues. (American Academy of Orthopaedic Surgeons. 2021) The longer the elbow remains out of the joint, the more damage can occur. Elbow dislocations rarely reset into their joints on their own and are recommended to be evaluated by a qualified healthcare provider to prevent permanent damage to nerves or function.
It is not recommended to try to reset the elbow on your own.
A healthcare provider will work to restore the joint and ensure proper alignment.
Before the reset, they will perform a physical examination to assess blood circulation and any nerve damage.
A closed reduction means that the elbow can be relocated without surgery.
Before the closed reduction, a healthcare provider will administer medications to help relax the individual and address the pain. (Medline Plus. 2022)
Once relocated into the correct position, a healthcare provider applies a splint (usually at a 90-degree angle of flexion) to keep the elbow in place. (James Layson, Ben J. Best 2023)
The objective is to prevent elbow extension, which can cause re-dislocation.
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