I like to do this exercise while walking, but you can get the same grip strengthening benefits from just doing it statically. Use of this type of splint showed improved outcomes, while still preserving repair integrity. To maintain a healthy throwing arm, we needed to provide evidence-based exercises that not only address strength but also address flexibility and endurance from the trunk to the hand. The prime function of flexor digitorum superficialis is flexion of the digits 2-5 at the PIP and MCP joints. Myers JB, Pasquale MR, Laudner KG, Sell TC, Bradley JP, Lephart SM. Philadelphia, PA: Lippincott Williams & Wilkins. Singh, V. (2010). Reading time: 7 minutes. An electromyographic analysis of the upper extremity in pitching. Bend your elbows to lower your chest, then push up by straightening your elbows. It is most likely an overuse injury, more common in runners, The PRICE principles are the gold standard set for treating sports injuries. Keeping your elbows straight, move your arms out to pull the band apart while moving your shoulder blades back, then slowly move your arms in towards the middle. A step-by-step ideal flexor tendon repair is as follows: Minimal but satisfactory exposure; A solid 4- to 6-strands core suture repair with slight bulkiness on the repair site; Tailoring of particular fingers flexor tendon repair with WALANT surgical setting. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. Available from: Tan J, Kim CH, Lee HJ, Chen J, Chen QZ, Jeon IH. Good results from direct repair can be expected due to absence of retinacular structures (if no neurovascular injury). Yet anyone seeking stronger forearms can benefit from this exercise. Sometimes this separation between the cut or ruptured ends of the tendon can be several centimetres. Following a suspected tendon injury, expanded examination techniques must be employed. To perform wrist flexion with a dumbbell, you should sit in a comfortable chair with your knees and legs slightly apart. and grab your free ultimate anatomy study guide! When refering to evidence in academic writing, you should always try to reference the primary (original) source. Published in: No composite wrist beyond 20 & combined finger extension until 6 weeks. 2014 Jun 1;6(2):196-202. Please try again. How to use putty to strengthen your fingers. Submitted for publication Int J Sports Phys Ther. If not caught early, it can be a difficult injury to, Groin inflammation or adductor tendonitis occurs when the adductor muscles in the groin become inflamed or degenerate through overuse. Since flexor digitorum superficialis is essential to the grasping function of the hand, injury can be quite disabling. If a tendon is frayed or if it was a tight repair - the patient might not be able to regain full range of motion. Put your palm on the base of your head and rotate to try to point your armpit towards the ceiling. Critical Body is the premier resource for learning how a sustainable exercise regime can improve your long-term physical health and mental wellbeing. The technique involves direct transfer of the long and ring finger FDS tendons to the third metacarpal bone. Sakata et al.8 highlighted the success of the YKB-9 program at not only improving muscular variables, but the YKB-9 program showed a 49% decrease in medial elbow pain in youth pitchers 8-11 years old. Lymphatic drainage of the upper limb occurs via the axillary lymph nodes.[1]. Wrist curls involves holding a weight in the hand with the palm facing up and then curling the wrist upward. Therapy sessions are usually twice a week for the first two weeks post-surgery. Peck FH, Roe AE, Ng CY, Duff C, McGrouther DA, Lees VC. For example, the tendon injury zone will dictate the splint design and the treatment process. Baz AAM, Hussien AB, Samad HMA, El-Azizi HMS. this may affect Flexor digitorum superficialis arises at two origin points/heads: From these origin points, the muscular heads of the flexor digitorum superficialis courses distally across the anterior forearm. Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. This is important for developing realistic expectations of the desired outcome, for both the therapist and the patient, This is important to design a joint treatment plan for patients with flexor tendon repairs, These patients can have quite complex injuries and having good and clear communication with the surgeon, will help in understanding the required rehabilitation protocol and also will benefit the patient, Keep tendons gliding to prevent adhesions, Aim for an active range of motion protocol where possible, Try to get a patient started with rehabilitation exercises before day 7 post-surgery. This anatomical variation in the muscle insertion can complicate diagnoses of injury to the smallest digit. Categories Forearm Muscles, Bones, and Anatomy Guide. Seaward JR, Peck F, Lees VC. Many flexor tendon rehabilitation protocols include place-and-hold flexion exercises. And, because it does more than just flex the wrist (more on its functions in a sec), its extremely important to keep this muscle strong and healthy if you want to avoid inures. FDP Tendon - the patient may show a sign of no active DIP joint flexion when the joint is isolated, FDS tendon repair - the patient may not have any active PIP joint flexion when the PIP is isolated, FPL tendon repair - the patient may not have any isolated IP joint flexion. https://nismat.org/education/injury-prevention/exercise-programs/nismat-arm-care-program/. Appendix A has photos and a link to the formal program. EMG analysis of posterior rotator cuff exercises. Moseley JB Jr, Jobe FW, Pink M, Perry J, Tibone J. EMG analysis of the scapular muscles during a shoulder rehabilitation program. Once the patient is able to return to his/her leisure activities, is able to use the hand functionally with few limitations and pain is under control, the patient can be discharged with a home program of continued stretching, scar management and strengthening exercises. Active flexion can start from day one post-surgery. 2016 Dec 1;138(6):1045e-58e. Rest your arm on a table with your hand hanging off the end and with your palm facing up. The acronym stands for Protection, Rest, Ice, Compression, and Elevation and should be, A calf strain is a tear to one or more of the muscles at the back of the lower leg. With elbows bent to right angles, pull the looped band apart by moving your hands out. Since the weighted carries/holds train both wrist flexion and finger flexion, theyre superior to regular wrist curls. With your elbows bent at right angles, twist your arms back so your hands come up on top. Set up in side-lying with the arm underneath the body. https://www.youtube.com/watch?v=hT0nR5d4Rnk. Register now Reviewer: Escamilla et al.26 highlighted the advantages of this internal rotation for maintaining internal rotation range of motion loss between innings.26 The NISMAT arm care program recommends performing this against a wall or side of dugout to maintain a more stable scapula. With your palm up, position the elastic resistance from the outside of your foot and grasp it between your thumb and first finger continuing the band through your palm so it comes to a rest past your pinky finger. The tendons that can be involved include: For the purpose of this page, specific anatomical details will be provided on the major muscles and tendons involved in flexion of the fingers and the ones most commonly injured. To give your flexor digitorum superficialis a good stretch, stand an arms length from a wall. These studies investigated early active motion (EAM) or true active flexion as opposed to early passive or place-and-hold flexion to determine which method is the most appropriate and has the most scientific support. Depending on the area of injury symptoms may include: Surgical repair is needed for a cut or ruptured tendons. that does not Your feet should not move, but your chest should face the band. The Hakan Alfredsons heel drop protocol involves twice daily, Gastrocnemius tendonitis is inflammation of the gastrocnemius tendon at the back of the knee. Scandinavian journal of surgery. Test your newly acquired knowledge on the flexor digitorum superficialis and other flexors of the forearm with our quiz! 2014 Jun;19(2):47-53. This can occur with an accompanying neurovascular injury. [1], The flexor digitorum superficialis coursesalong the volar aspect of the forearm, superficial to the flexor digitorum profundus and flexor pollicis longus muscles, and deep to the palmaris longus, flexor carpi radialis, flexor carpi ulnaris, and pronator teres.[1]. Flexor tendon glides: 2 x 10; 4 times per day These help to isolate the affected muscles in a gentle manner.6 The various positions activate your FDP and FDS, taking you through a full range of motion. The goal of the rehabilitation exercises after a flexor tendon repair is to[9][15]: Various different protocols have been developed for the rehabilitation of flexion tendon repairs. 58 NBA players: Can you play basketball if youre 5 foot 8? Slow and smooth is the name of the game here. Median nerve (C7, C8, T1) [1] Artery. set a cookie on your device to remember your preferences. Silicone gel sheeting can be used on the scar or paper tapes or products for scar management such as Fixomull. During surgery, the wound is enlarged so that the cut ends of the tendon can be found and held together with stitches. We have gained a better understanding of the muscular performance demands through the EMG studies of the pitching motion.1,2 As clinicians we are continually looking to prepare our athletes for peak performance and injury prevention. The cookies collect information in a way Treatment is usually direct end-to-end tendon repair. This program was designed to utilize elastic-resistance exercises with no additional equipment required. Hand. This happens in ball sports where a finger is forced into extension while it is being flexed or where a player grabs an opponent's shirt (jersey finger) or in activities such as rock climbing.[12]. The type of orthosis/splint that will be used in a patient is often prescribed by the surgeon and therapists will need to discuss the appropriate choice of splint with the surgeons that they work with. Rehab My Patient. Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. Our team has accomplished our 3 goals for developing the NISMAT Arm Care program. The scapular muscles play a large role in the stability and foundation of the throwing arm. Zones 2-5 Flexor tendon repair Protocol, https://www.youtube.com/watch?v=nrZdYJdrSCo&app=desktop, Diagnostic performance of high-resolution ultrasound in pre- and postoperative evaluation of the hand tendons injuries, Epidemiology of complex hand injuries treated in the Plastic Surgery Department of a tertiary referral hospital in Warsaw, https://www.orthobullets.com/hand/6031/flexor-tendon-injuries, https://www.bssh.ac.uk/patients/conditions/26/flexor_tendon_injury#What_is_the_treatment_, https://www.youtube.com/watch?v=zWN8qSIDGjQ, https://www.youtube.com/watch?v=4NZ2drULuzc, https://www.youtube.com/watch?v=wtSn4B8lKm4, Rehabilitation following zone II flexor tendon repairs, https://www.ncbi.nlm.nih.gov/pubmed/25700105, https://www.physio-pedia.com/index.php?title=Flexor_Tendon_Injuries&oldid=322945, Incidence rate of 33.2 injuries per 100 00 person-years. Upon passing the metacarpophalangeal joint, the two tendons enter the digital flexor sheath. The hand gripper is a good alternative. But, for the benefit of your posture, I recommend doing this drill while sitting in a chair. Patients always do their exercises with the splint, so that there is no risk of extending the fingers and rupturing or putting the tendon at risk. From the late cocking to the deceleration phase the serratus anterior maintains an EMG level between 51 and 106% Maximum Volitional Contraction (MVC) with the peak MVC occurring during late cocking.2 To help address the serratus anterior we chose the push-up plus. Start with both hands-on thighs, engage core and raise arms up in the scapular plane (approximately 45 from frontal plane). Legrand A, Kaufman Y, Long C, Fox PM. You may disable these by changing your browser settings, but Hold the dumbbells by your sides and maintain a good, upright posture. It is one of the wrist and hand flexor muscles. Its also little surprise that a muscle this large (large for the forearm, that is) has two distinct heads. Rotate as high as possible without compensation, and slowly return to the starting position. The degree of metacarpophalangeal flexion was decreased to 30 and a hand-based orthosis was incorporated.[18][19]. After the surgery, the hand and forearm are immobilised in a splint that is placed over the bandages with the wrist and fingers in a slightly bent position, in order to protect the repair.[14]. Extensor Digitorum Communis is sometimes simply referred to as Extensor Digitorum. Tendons can retract if vincula are disrupted. Additionally, the deep layer gives off a small slip that joins the tendon of the superficial layer directed to the digit 2. This work set the stage for researchers like Mosely et al.3, Blackburn et al.4 and Townsend et al.5 to investigate which exercises would be most beneficial for the throwing athlete, allowing innovators like Kevin Wilk and James Andrews to develop the Throwers Ten Exercise Program in 1991.6. Repeat the movement for 2-4 sets and increase the time under tension to 45-60 seconds once the initial 30 seconds become easy. Instead of place-and-hold exercises, therapists are now using more progressive protocols and are asking patients to perform active flexion to half a fist with active extension into the back of the splint. Edinburgh: Butterworth Heinemann, Elsevier. The extensor carpi radialis brevis is important in racket sports and golf which require strong wrist extension (movements where the wrist bends backwards). The other digits should remain in the extended position. This results in improvements in DIP joint flexion and differential glide. Once the wound is healed, scar management can commence. 1173185. The American journal of emergency medicine. Plastic and Reconstructive Surgery Global Open. Flexor digitorum profundus passes between the two slips of flexor digitorum superficialis, through a space called Campers chiasm. Grasping the band with palm up you will now pronate or try to turn palm down. Blackburn TA. Escamilla RF, Yamashiro K, Mikla T, Collins J, Lieppman K, Andrews JR. We'd like to set Google Analytics cookies to help us to improve our website by The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. By expanding on the findings of the previous study, researchers were able to develop a novel method for examining the FDS. WebThis motion gently mobilizes your flexor tendons by putting them on slack and then tensioning them. Here are some examples of flexor tendon injury rehabilitation protocols: Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Flexor carpi ulnaris muscle (Musculus flexor carpi ulnaris) Flexor carpi ulnaris is a fusiform muscle located in the anterior compartment of the forearm.It belongs to the superficial flexors of the forearm, along with pronator teres, palmaris longus, flexor digitorum superficialis and flexor carpi radialis.Flexor carpi ulnaris is the most medial Some red flags that therapists need to look out for when treating patients with flexor tendon injuries include[9]: Some key messages to remember with flexor tendon injury management[9]: After optimising the repair, the therapist team works with the surgeon to select a rehabilitation plan that protects the repair but helps to maintain tendon gliding. Variant muscle to the little finger originating from the flexor digitorum superficialis. Zone is unique in that FDP and FDS in same tendon sheath (both can be injured within the flexor retinaculum). The Manchester short splint: a change to splinting practice in the rehabilitation of zone II flexor tendon repairs. Then slowly and in a controlled fashion, let the weight take your hand back down to neutral. 5th Edition. The skin that overliesthe muscle is supplied by roots C6-8 and T1. 8 Understanding the limitations of an 18-exercise program, the mYKB-9 was slimmed down to 9 exercises, and after a 1-year follow-up, a reduction While standing, hold two ends of a resistance band. A Systematic Review of Electromyography Studies in Normal Shoulders to Inform Postoperative Rehabilitation Following Rotator Cuff Repair. Flexor Carpi Radialis is a wrist muscle which also crosses the elbow joint and so is also a weak elbow flexor. But before we get into the specific flexor digitorum superficialis exercises, lets take a quick anatomy recap to understand how this important muscle functions. Carpi to do with the carpal bones in the wrist. Medial coronoid process. Curated learning paths created by our anatomy experts, 1000s of high quality anatomy illustrations and articles. reporting information on how you use it. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. There is always a risk of infection with any surgery and if any signs of infection are present, it is important to get in touch with the surgeon. Grab two heavy dumbbells (remember, heavy is relative) that you can hold for around 30 seconds (it may take trial and error to find your ideal weight). 2019 Aug 1;44(8):680-6. Subscapularis activation reaches its peak MVC during the acceleration stage of pitching (115%).2 This exercise has been shown to reach between 65-71% MVC.12,22 The NISMAT Arm Care program recommends performing scapular stabilization prior to performing this exercise. During this step we determined there was little evidence supporting exercises for the flexor pronator mass. We won't set optional cookies unless you enable them. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. This article will discuss the anatomy and function of the flexor digitorum superficialis. Some studies report that extensor tendon injuries occur more frequently than flexor tendon injuries, Majority of cases involve a single tendon, extensor tendon injuries involves Zone III of the index finger and flexor tendons involve Zone II of the index finger, Common injury in people working in physical construction jobs, using saws, glass or getting metal lacerations, Also common in people working in food preparation with knife injuries, In recent years, the media has highlighted the increase in tendon injuries as a result of poor avocado de-seeding technique. The goals of developing the NISMAT Arm Care program were: (1) Exercises should be evidence-based. The progression of evidence-based arm care has taken generations of innovators to get to where we are today. So graded exercise program or rehabilitation program is necessary for physiotherapy treatment based on cause, assessment findings and patient-centered goal[10]. Flexor digitorum superficial splits into radial and ulnar slips prior to insertion on middle phalanx. Available from: Presazzi A, Bortolotto C, Zacchino M, Madonia L, Draghi F. Aljawder A, Faqi MK, Mohamed A, Alkhalifa F. Sarah Tucker Oxford. 2. But on this occasion, I think that the conclusion is pretty cut and dry. Massaging the scar as much as possible is necessary and getting the skin to glide freely from the underlying tendons, It is important to prevent adhesions right from the beginning. Exhale on rotation. You can increase the resistance on each Powerweb by increasing the number of grids within your grip. The flexor digitorum superficialis and flexor digitorum profundus have two vinicula each. Flexor digitorum superficialis; Flexor pollicis longus; Abdomen. In 2011, Wilk et al.7 introduced the Advanced Throwers Ten. 2013 Jun; 5(2):138-44. This exercise was chosen for activation of the pronator teres. WebThe present article describes a novel technique of transferring 2 flexor digitorum superficialis (FDS) tendons for wrist extension for patients with radial nerve lesions. Wilk KE, Yenchak AJ, Arrigo CA, Andrews JR. Reinold MM, Macrina LC, Wilk KE, et al. WebFlexor Digitorum Superficialis and Profundus Repair Early Active Motion Protocol Copyright 2020 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. Edinburgh: Churchill Livingstone. Manninen M, Karjalainen T, Mtt J, Flinkkil T. Epidemiology of flexor tendon injuries of the hand in a Northern Finnish population. Edinburgh: Elsevier Churchill Livingstone. This exercise was chosen to address lower trapezius muscle strengthening. This exercise was chosen to address supraspinatus, middle trapezius, and posterior deltoid. There are several different ways to strengthen the finger flexors using the power web. Anterior interosseous nerve syndrome diagnosis and intraoperative findings: A case report. Flexor Tendon Repair Postoperative Rehabilitation: The Saint John Protocol, Brigham and Women's Hospital. Direct end-to-end repair of FPL is advocated. Krause DA, Dueffert LG, Postma JL, Vogler ET, Walsh AJ, Hollman JH. The post-surgical wound may be dressed with a basic silicone dressing (products such as Mepitel may be used). WebWhen the flexor digitorum profundus tendon would not glide under the A2 pulley, we excised the remaining slip of the flexor digitorum superficialis tendon. The posterior deltoid reaches levels of 93% MVC during this exercise.5, This exercise was chosen to address both lower trapezius and posterior deltoid strengthening. 2023 Rarely, carpal tunnel syndrome can be caused by an aberrant muscle belly arising from the tendon of flexor digitorum superficialis that compresses the median nerve. Perform a row by pulling the band and bringing your elbows back to the level of your chest. Sorry, something went wrong. McCabe RA, Orishimo KF, McHugh MP, Nicholas SJ. The new technique does not involve the excessive applied force required by conventional methods. I would honestly say that Kenhub cut my study time in half. May require A1 pulley release to avoid impingement of the repaired tendon on the pulley. A person can exercise the flexor digitorum superficialis by performing wrist curls. For more information on how these cookies work, please see This expanded program incorporated throwing motion-specific exercises and movement patterns performed in a discrete series, utilizing principles of coactivation, high-level neuromuscular control, dynamic stabilization, muscular facilitation, strength, endurance, and coordination, which all serve to restore muscle balance and symmetry in the overhead throwing athlete.7 The evolution of these arm care programs has been an asset to the baseball community, offering the opportunity for pre-season and off-season strengthening for injury prevention and sports performance. Lower the dumbbells towards the ground until you feel a deep but comfortable stretch. Do you find it difficult to memorize the anatomy of over 600 muscles? Sakata J, Nakamura E, Suzuki T, et al. Anterior interosseous nerve (AIN) syndrome: Anterior Interosseous nerve is the motor nerve that runs deep in between flexor digitorum profundus and flexor pollicis longus. Zone I, II and III injuries of the flexor digitorum profundus and/or the flexor digitorum superficialis, This promotes the arc of flexion to be activated by the long flexors, rather than the intrinsics. WebFlexor ((Active PIP + DIP) PIP TAM tendon repair zones 1-3 Early Active Motion (EAM) This protocol is intended to provide the clinician with a guideline for the postoperative rehabilitation course of a patient who has undergone primary 4- or 6-strand flexor digitorum superficialis and/or flexor digitorum profundus repairs in Zones 1-3. The repair may be performed under general anaesthetic or regional anaesthetic (injection of local anaesthetic at the shoulder). Forearm-based metacarpophalangeal joint (MCP) extension blocking splint with wrist in neutral and MCP's in around 30 of flexion. Continue to raise arms in this position, with thumbs pointed towards the ceiling, until you reach approximately 100. Flexor this means the muscle flexes the wrist or thumb. (forwards and centers). Flexor tendon injuries are some of the more common and complex injuries managed by hand surgeons. A good understanding of the treatment procedures, healing stages, clinically relevant anatomy and rehabilitation of these injuries is necessary for a satisfactory outcome in the patient with a flexor tendon injury. For example, if a patient is referred for therapy at 8 or 9 days post-surgery and the patient has not had any therapy yet, the therapist would probably not want to start with active range of motion exercises as the tendon is at its weakest from day 8 to day 21 post-operatively. Forearm Muscles, Bones, and Anatomy Guide, Average NBA height by basketball position. Scar massage can be done during therapy sessions and at home to prevent adhesions.[9]. Step 1: The Arm Care team first reviewed the early pioneering EMG studies identifying which muscles were activated during the pitching motion.1,2 This enabled our team to develop a list of muscles that needed to be addressed in an arm care program. [2] Andlucky youthats exactly what Ive done here. Arm care is an evolving process that needs to be re-evaluated based on the continually changing literature. It allows differential glide between the FDP and FDS tendon, as flexion is initiated by the FDP tendon in this position. Often associated with neurovascular injury which carries a worse prognosis. But since most people do this exercise slumped in a chair rather than while walking (as with the static holds), it doesnt have as much functional carryover to everyday activities. Improving outcomes in tendon repair: a critical look at the evidence for flexor tendon repair and rehabilitation. Its large muscular belly courses distally towards the wrist, where it splits into four tendons and attaches to the middle phalanges of the second through fifth digits of the hand. That is usually the journal article where the information was first stated. Anchor the middle of a resistance band on a secure object at about waist height. Digiovine NM, Jobe FW, Pink M, Perry J. Loading [Contrib]/a11y/accessibility-menu.js. Squeeze the dumbbells to engage your forearms and maintain this hold for 30 seconds. 2022. How to improve finger strength using putty. Bullock GS, Strahm J, Hulburt TC, Beck EC, Waterman BR, Nicholson KF. This exercise was chosen for activation of the supraspinatus, middle deltoid, and teres minor. Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. Place the dumbbell in your hand and flex your wrist which will bring the dumbbell towards your body. Heres how to do it: Grab a pair of light dumbbells and place the top of your forearms on a bench (or table) so that your palms are facing up. WebOrigin, insertion, functions, and exercises for the Flexor Digitorum Superficialis. Flexor Digitorum Superficialis - Everything You Need To Know - Dr. Nabil Ebraheim. After the number of repetitions in this pattern, switch directions for your arms and repeat. As you are pressing down, lift your heels as high as you can while keeping the balls of your feet on the floor. [8] These tendons are not well-vascularised and there are some avascular areas that receive nutrition by diffusion. https://www.youtube.com/watch?v=9lSOE1CbJYw. Anatomy of Upper Limb and Thorax; London: Elsevier Health Sciences. With your hands placed at shoulder height and shoulder width alternate walking up the wall with the pinky side of the hand. 2020. List 7 foot NBA players and basketball players over 7ft. It is important to know and have a good understanding of the different tendon zones as this will: Tendon zones differ for the extensors and the flexors. Perform three sets of ten then switch arms. The main action of this muscle is flexion of the digits 2-5 at both the metacarpophalangeal and proximal interphalangeal joints. WebFlexor Digitorum Superficialis (FDS) tendon - isolate the involved/affected finger and ask the patient to flex the proximal interphalangeal joint (PIP) Flexor Pollicis Longus tendon - flexing the interphalangeal joint (IP) joint of the thumb in isolation; Radiographs - may have associated fracture Insertion. It is found in the palm side of the forearm and wrist. Other products that therapists may use include Coban, but a good, comfortable, clean and a dry dressing is acceptable as well. Carpal tunnel syndrome is most commonly caused by a combination of factors that reduce the space around the median nerve, such as swelling due to injury, inflammation or a neoplasm.