Injuries to watch heading into 2009

We all know that when it comes to drafting your fantasy baseball team, understanding a player's injury history can be just as important as knowing whether he can consistently hit for power against left-handed pitchers or whether his K/9 ratio has dipped. It's no longer enough to know that the guy you may be eyeing for your team missed some time last year. Now you need to know whether that injury is an indicator that he's likely breaking down, or whether it was a one-and-done fluke scenario.

That's why we're here. Navigating the world of medicine is challenging enough when you have all the information at your fingertips. It's infinitely more difficult when you have access to only part of the story, as is usually the case in sports. Our job is to help you make sense of what information you do have, so that you, the GM of your fantasy team, can make the best-informed decisions on draft day.

On that note, here's what we have on deck for you in 2009.

  1. A brief summary of some of the key injuries you are most likely to see on a baseball field. Some injuries favor hitters, while others are more likely to take out a guy who makes his living on the mound, and sometimes there's no predicting (like Yovani Gallardo's going down randomly with an ACL tear last year). Given that you're likely to hear these terms in relation to one or more eligible fantasy baseball draftees this year, it's best to have some familiarity with what they mean in terms of impact.

  2. An injury rating key. Almost everything in medicine is rated on a scale of threes. Ligament sprains are graded I (no big deal), II (the hardest to interpret) and III (completely gone, done, forget about it). Muscle strains are graded on a similar scale. Everything else, from illness to damaged tissue, is described by one of three terms: mild, moderate or severe. You hear things like, "He has mild arthritis in his knee," or, "He had a severe case of the flu." So it only makes sense to continue the trend of a three-pronged scale with our player injury rating. And surprise, surprise! Baseball has the perfect analogy with its three-strikes-and-you're-out system.

    • One strike: So this player has had an injury. So what? It's not one that overly concerns us. It's either minor enough to leave our feathers unruffled or it has a recovery time frame and rate that makes us comfortable this player will be back for the bulk of the season. High confidence rating.

    • Two strikes: This might be the most difficult rating, so draft with caution. Just as a Grade II sprain or moderate injury spans the largest range in medicine, so does the two-strike notation. These are players who have had an injury that has a less certain outcome, or may allow the player to only be available for a portion of the season. Players rated here may have high upside but come with some risk of reinjury, or risk of delayed return from an offseason or spring-training injury.

    • Three strikes: It seems to state the obvious: stay away. But you could also use this ranking to make some calculated moves. Most guys who get a three-strike rating are going to be on everyone's radar as an injury risk. But as with life, there are no guarantees when it comes to injuries. Occasionally, one of these players will emerge late in the season or stay surprisingly healthy, making him a late-round value for you when no one else will touch him. Don't say you haven't been warned, though. This guy comes with a high risk attached.

  3. Notes on some of your favorite players and why their injury issues either concern us or don't. Combine the injury notes with our analysts' fantasy rankings and insights to help you prepare your strategy for draft day.

Keep in mind that injuries do have a way of happening on their own time frame despite our best efforts to prepare you. So check back frequently, as we will update this section as injury news develops leading up to Opening Day.

Chase Utley, 2B, Philadelphia Phillies
Strikes: One

The Phillies' All-Star second baseman underwent arthroscopic surgery on his right hip in November to address issues with the labrum and the cartilage surface. He was initially projected out until possibly late May or June, but now it seems he could be ready for Opening Day. In fact, with each passing day, as he meets one spring-training challenge after another, Utley looks as if he will indeed be in the Opening Day lineup.

Utley has already participated in several spring-training games. In order to do that he had to pass the toughest drill for his surgically repaired hip: sliding. Once he demonstrated that he could slide without hesitation and, more importantly, have no residual discomfort the following day, everyone in the Phillies organization could breathe a deep sigh of relief. Now he has proved that he can run; slide; and, most recently, charge the ball and pivot, all of which show confidence in his hip.

The Phillies have made it clear throughout Utley's recovery that their main interest is having him available for the bulk of the season, and they stressed that there would be no risks taken to jeopardize that. He also clearly understood the importance of progressing at a controlled pace and not overdoing it along the way. That measured approach, along with his overall fitness and work ethic, appears to have paid off. With no setbacks thus far, the likelihood of anything untoward happening diminishes daily. Expect Utley to have a productive and solid season.

B.J. Upton, OF, Tampa Bay Rays
Strikes: One

Rays center fielder B.J. Upton had problems with his left shoulder last season, and it showed, primarily in the form of decreased power. But when he had a surge in that power during the Rays' postseason run, it surprised some that Upton went under the knife anyway in November to address his shoulder.

Upton had surgery to repair a torn labrum, and given the nature of the problem and his inconsistency last year, his decision to have it repaired was not that surprising. The labrum is a fibrocartilage ring that helps provide extra depth to the shoulder socket, thereby enhancing its stability. When damaged, the labrum can catch and pinch inside the joint, as it often does with throwers, during overhand motions or can contribute to an overall feeling of shoulder instability.

For a hitter, this type of injury on the non-throwing arm can be very painful, particularly on a swing and a miss. In the absence of contact, the shoulder can slip in the joint, or even sublux (where it slips partially out of the socket but does not dislocate), causing irritation to the surrounding soft tissue that can take days or weeks to subside. One such episode can make a batter more hesitant at the plate, for fear of incurring another potentially worse episode of pain. If no repeat episode occurs for a while, the batter can gradually regain confidence and potentially even return to a normal swing. Until it happens again. This could explain why Upton had a period of decreased productivity last year, followed by a strong performance in the postseason.

Frustration can arise with the on-again, off-again nature of the problem, and Upton acknowledged that the shoulder had bothered him for years. He is now progressing steadily but cautiously -- which is reasonable after this type of procedure -- and although he may not be ready for Opening Day, he should make his return soon afterward.

Last year, Marlins shortstop Hanley Ramirez made a successful return after a very similar offseason surgery, showing that there is precedent for Upton. Expect his debut to come in warm-weather games at home, and it may take him some time at the plate to regain his power. But as he gains confidence in his now stable shoulder, Upton should be able to produce at the plate the way he and his fantasy owners expect.

Chris Carpenter, P, St. Louis Cardinals
Strikes: Two

No one needs to tell Chris Carpenter that the past couple of seasons have been rough. He has spent more time in rehab than on the mound, having made only four starts in the past two years. Ongoing problems in his throwing arm, starting with bone spurs in 2007, then ultimately ulnar collateral ligament reconstruction (Tommy John surgery) in the middle of that year, kept him out until the middle of 2008.

When Carpenter did return, he developed right-shoulder problems that were attributed to nerve compression, which ultimately shut him down. In November he underwent a nerve transposition at the elbow after having discomfort during workouts. The ulnar nerve, which runs behind the funny bone at the elbow, can sometimes be symptomatic even after ligament reconstruction. By moving it from behind the funny bone to the front of the forearm, there is less traction on the nerve and symptoms typically go away. In the meantime, the nerve issue in his shoulder has also reportedly improved.

Although these are listed as separate problems, when an athlete is challenged by injury as much as Carpenter has been recently, the body can compensate and create problems at different points along the chain. In the case of a thrower, the problems can show up anywhere from the neck through the entire arm and hand, and Carpenter certainly has seen his share.

The good news is that Carpenter has looked strong thus far in spring training. He has pitched 12 scoreless innings at this point; his velocity has improved; and most important, he feels good. He is currently set to be the fourth starter in the Cardinals' rotation. All signs are positive for Carpenter so far, but there are no guarantees. If there is any silver lining to his extensive missed time, it's that he has limited the wear and tear on his arm during that period, which could end up increasing his overall longevity.

There is good reason to be optimistic based on what Carpenter has shown through spring training. But there is no getting around the fact that he has had various arm ailments over the past two years, which warrants some caution.

Cole Hamels, P, Philadelphia Phillies

Strikes: One

No one wants to see their 25-year-old pitching ace, who happens to be the World Series MVP, leave spring training with elbow stiffness. But if said ace flies home to Philadelphia to have the team doctor examine his elbow, you just have to hope for the best. Frankly, the Phillies got just about the best news possible in this situation: Hamels has no structural damage, and, according to the Phillies' official Web site, the inflammation is on the posterolateral part of his elbow (the back outer corner, making it likely early tendinitis), not the medial or inside part, where the ulnar collateral (Tommy John) ligament is.

Hamels was not particularly symptomatic, experiencing tightness only between innings, not during throwing, which is consistent with very early tendinitis. Treating it early with a cortisone injection to reduce inflammation and resting him now, even if it means that he sacrifices an Opening Day start, makes for a better chance that Hamels stays healthy across the season. Many pitchers experience similar things during spring training. After all, that's why spring training exists, to allow players to work through some of the rust of the offseason and gradually rebuild their tolerance for the marathon that is the regular season. Even Hamels acknowledges that a slow start is routine for him, but that start will now be just a bit slower. Although Hamels is still hopeful to start on Opening Day, the team will not force it, which is the wise long-term approach.

Let's face it: All pitchers are always at risk for shoulder and elbow problems. Period. Based on the mild nature of his symptoms and the absence of significant findings during his medical exam, Hamels is no more or less likely than any otherwise healthy pitcher to have a problem this season as a result of this incident.

Troy Glaus, 3B, St. Louis Cardinals
Strikes: One

The perception is that Glaus has an injury cloud hanging over his head, and to be fair, he has seen his share of ailments. But it is also worth noting that he has still played in the bulk of regular-season games over the past few years.

This year he enters the season coming off arthroscopic surgery in January on his right (throwing) shoulder, which has given him trouble for some time. Glaus underwent surgery to repair the subscapularis muscle, one of the four muscles that comprise the rotator cuff. This procedure is actually a good move long term. He had experienced pain in the shoulder for several years, and had previously tried cortisone shots, rest and rehabilitation. Despite short-term benefits, the symptoms persisted, according to the St. Louis Post-Dispatch, often causing him pain during a swing of the bat or a throw. He elected to undergo exploratory surgery in January despite the lack of definitive findings on MRI after his latest attempt to rest the shoulder was unsuccessful.

The tear was found and addressed during the surgery and his projected timetable has him returning in May. As of March, Glaus has begun doing some light toss, but as the Post-Dispatch reports, he still has yet to swing a bat or throw with intensity. Aside from the muscle injury, his shoulder was found to be structurally intact, which bodes well for the long haul. With his past foot problem (plantar fasciitis that required nerve decompression) well behind him and his body well rested coming off surgery, Glaus should be in good shape for the season once he returns. Although he is now on the other side of 30 and does have some injury problems in his past, there is no reason to think he can't have a solid season in 2009.

Josh Beckett, P, Boston Red Sox
Strikes: One

During spring training last year we were talking about a back problem that Beckett developed right before the start of the season. This year the buzz is about the fact that Beckett is in visibly better shape. Red Sox pitching coach John Farrell told The Providence Journal at the outset of spring training that the extra few weeks of recovery that Beckett had in the offseason likely contributed to him being better rested. Manager Terry Francona added that Beckett was "in good shape and … raring to go."

It's true that Beckett dealt with several injuries (back, oblique and, perhaps most worrisome, some right elbow inflammation) across the 2008 season, but none turned out to be major. Better yet, his elbow was thoroughly examined by Dr. James Andrews last summer and was found to be structurally sound. Outside of some blister problems in the past, Beckett has been largely durable thus far in his career. Coming off extra rest and being in better shape in 2009 can only be viewed as positive signs. Expect good things.

David Ortiz, DH, Boston Red Sox
Strikes: One

Big Papi was just not himself last year, still showing some residual effects from his meniscal surgery when the season opened, only to suffer a left wrist injury (partially torn tendon sheath) in May that led to 45 missed games. The time off to heal the wrist allowed his knee to improve, but his wrist continued to give him some trouble at the plate throughout the remainder of the season.

Just when it looked as if the 30-something power hitter might be nearing his peak, he took it upon himself to embark on an offseason fitness and conditioning regime that had him arriving in camp lighter but stronger than at the start of 2008. By late February he was displaying his signature power, hitting multiple 450-plus-foot shots into the outfield according to the Boston Herald. His two-run homer in a spring training game this week suggests that he is swinging the bat well in live-action play as well.

The rest and the conditioning can only work in his favor and the fact he is off to a good start early is extremely encouraging. Despite the recent spate of injuries, Ortiz's health stock actually goes up this year with the new and improved version of (the slightly less big) Big Papi.

John Smoltz, P, Boston Red Sox
Strikes: Two

Sure, you may be thinking it's crazy that Smoltz is not in the highest risk category. After all he's not exactly the picture of youth at 41 (make that 42 in May), has had a litany of elbow problems in the past and is coming off extensive shoulder surgery which, frankly, would have forced many of his peers into retirement. But he is no ordinary pitcher.

Even when he headed into surgery, Smoltz was careful to refer to it as season-ending, not career-ending, adding that he would do "everything [he] possibly can to continue to pitch." Apparently, he has done that. After his June surgery, Smoltz was told by Dr. James Andrews that he had to repair significant damage. Smoltz then diligently went to work, and was impressive enough in his winter throwing sessions to catch the eye of the Red Sox's brass. The Red Sox had to feel confident about Smoltz's status and his expected progression to play since their rehabilitation coordinator and assistant athletic trainer, Mike Reinold, used to work side by side with Dr. Andrews in Birmingham, Ala., and knows firsthand how to guide such players back to a successful return. Key to that success is a gradual timetable, and Smoltz seemed comfortable that he would not be pressed into service before he was ready. The Red Sox have tentatively indicated that he is expected to return in June. With his first bullpen session expected in about a week, the timetable certainly appears within reach.

Smoltz is realistic about his longevity in the game, as evidenced by his accepting a one-year contract. But beware, naysayers: He is as competitive and determined as ever and might, just might, go out and have his best season in three years.

Jorge Posada, C, New York Yankees
Strikes: Two

The 37-year-old catcher told Newsday recently that he is "back to 100 percent" after surgery on his right (throwing) shoulder in July. But he is 37 and a catcher. Those two facts really account for the two strikes against him.

Posada, the Yankees' ace behind the plate, is recovering from surgery to address a torn labrum and clean up his rotator cuff. Not only is Posada known for being largely consistent swinging the bat, but he also has a strong defensive arm that's so critical to his position. In fact, last year when Posada was ailing, it was evident in his lack of power at the plate and when he struggled defensively.

Posada underwent surgery with Dr. David Altchek, chief of the Sports Medicine and Shoulder Service at the Hospital for Special Surgery in New York, who also happens to be a team physician for the Mets. It's hard to be in better hands for surgery, and the outcome so far is as good as could be expected. Posada is clearly gaining confidence and strength as he moves through his spring training rehabilitation, most recently evidenced by his throwing out three base stealers in a single minor league exhibition game. The speed and accuracy required in this situation place as much demand on the shoulder as just about anything Posada will have to do, so it certainly inspires confidence that he is well on track.

So why the rating? It really is an indicator of risk based on his age in baseball years and the position that he plays that requires caution in the presence of optimism. Yankees general manager Brian Cashman summed it up best when he told the New York Post: "It has gone as well as we could hope thus far. So we are hopefully cautious. So far, so good, but I don't want to count my chickens."

At 37, Posada is riskier for breakdown, and not necessarily just at the shoulder. His body has endured its share of wear and tear at his position, and it does add up. As a catcher, Posada needs to throw as many times as, and frequently more than, a pitcher. Granted, each toss is not as hard, but hard, long throws are required intermittently. He also has to endure collisions at the plate. An outstretched arm to make a tag puts a still-recovering shoulder at more risk. So far, so good indeed for Posada, but the risk factors are undeniably part of his picture.

Joe Mauer, C, Minnesota Twins
Strikes: Three

No one would argue that Mauer is one of the best at his position. Nor would they likely argue that he has dealt with some unusual injuries in his young career. He had a slew of left-side injuries, starting with a significant knee injury (torn meniscus) in 2004, followed by a stress reaction (leg), a strained quadriceps and a strained hamstring in 2007. His most recent ailment is on his right side, however, and it takes the cake when it comes to the realm of unusual.

It began last fall when, in the course of trying to uncover the source of his ongoing back pain (which was so bad in October, according to Phil Miller of the St. Paul Pioneer Press, that Mauer had difficulty walking), doctors discovered a kidney obstruction that apparently had been present, but unidentified, since birth. Mauer underwent surgery in December to correct the kidney blockage. The hope was that the back pain would improve as a result, and it did for a time. But keep in mind, he was recovering from surgery and was therefore not nearly as active as he otherwise might be, so it makes sense that his back might feel better simply from rest.

Not long into spring training, however, Mauer's symptoms returned. The pain reportedly limited him primarily with running, but as Miller noted, although Mauer was doing some agility drills and conditioning, he had not yet caught for more that 10 minutes at a time and had not yet faced live pitching. In other words, this debilitating back pain was apparently not the result of heavy-duty baseball activity.

Mauer has since undergone further testing, including consultation with outside "specialists," according to the Twins (their practice specialty has not been identified, but Joe Christensen of the Minneapolis Star-Tribune reported that general manager Bill Smith indicated they were specialists on the sacroiliac joint), and the conclusion is that he has inflammation in his right sacroiliac joint (where the sacrum, the bone at the base of the spine, meets the ilium, the primary bone of the pelvis). The only problem with this conclusion is that it describes a symptom as opposed to a diagnosis, which poses more questions than answers.

Inflammation of the sacroiliac joint is highly unusual, and when it does occur, it is usually the result of trauma (such as a fall or motor vehicle accident), or extreme shear stress. This is not your garden-variety athletic injury. Even Smith told MLB.com that "it's been a little bit perplexing, the pain." It could be argued that there is something about the stresses associated with Mauer's position that led to this. But it is a condition that has no particular association with catchers, and Mauer had not been actively playing the position since September, making it less likely he would have sports-related inflammation. There are other conditions associated with sacroiliac inflammation that are unrelated to trauma or athletics, but the Twins have not elaborated on what the purported cause is, saying only via manager Ron Gardenhire that the plan is to treat Mauer with "something more aggressive" for the inflammation.

Normally youth is favorable when it comes to injury recovery, especially when it's a typical musculoskeletal injury (i.e. tendinitis, muscle strains, etc). But the atypical nature of Mauer's symptoms, the length of time they have persisted, and the lack of a clear-cut source of the condition combine to create uncertainty. The best hope for Mauer is that his new course of medication will indeed help him get through this episode and that it will not recur or lead to something else. His timetable for return remains unclear, though, as does his outlook for the season.

Albert Pujols, 1B, St. Louis Cardinals
Strikes: One

Despite concerns about Pujols' elbow (yes, the one with the injured right ulnar collateral ligament, otherwise known as the Tommy John ligament) heading into last season, and despite his pronouncement before the 2008 season that he would not subject his body to undue stress (read: more days off), he played in only 10 fewer games than he did in 2007. And part of that time off was forced on him as a result of a calf strain, not because of the elbow (although he did tell me at the All-Star Game that the rest certainly didn't hurt his elbow). The point here is that despite known ligament damage, Pujols held up, which actually makes his 2009 season more promising.

It might seem odd that an athlete with a known injury that now has another year of wear and tear on it is in better shape for the upcoming season, but there are reasons to be optimistic. Pujols actually underwent surgery in the offseason, not to address the ligament itself, but to address the ulnar nerve, which is often irritated and pain-producing in these situations. By moving the nerve from behind the "funny bone" at the elbow, otherwise known as the medial epicondyle, to a more anterior position on the forearm surface, the nerve is subject to less stretching or traction. (Note: This is the same procedure that teammate Chris Carpenter underwent last year.) Nerves tend to prefer less stretch on them, and the response is often a decrease in nerve-related symptoms, which can include numbness, tingling or even pain along the path of the nerve itself.

Pujols has already indicated that he feels better this spring having had this surgery. Sure, his ligament could completely fail at any time, but it's actually uncertain whether that would set him back much further. Since he is not a pitcher, he does not rely on his elbow in the same way, and it may be that his compensations thus far could carry him, at least for a while. At some point the elbow will likely need to be addressed, and knowing it is less than perfect requires us to list him among the injury risks. All things considered, however, including the production and consistency you can expect from him, Pujols actually enters this season in a more favorable position than last year.

Trevor Hoffman, P, Milwaukee Brewers
Strikes: Two

This injury rating shouldn't come as a surprise simply because of Hoffman's mature age of 41 (which in baseball years probably approaches triple digits). He has continued to perform as a solid closer, although last year he gave up more home runs per 9 innings, and his total innings workload was down. Are these signs of an impending demise?

Not necessarily, but starting off on the disabled list might be. Baseball's all-time saves leader is reportedly dealing with a strained right oblique muscle that he sustained in mid-March. The interesting thing about Hoffman's injury is that it does not follow the pattern typically associated with pitchers, which is an injury to the contralateral side (the side opposite the throwing arm).

On the one hand, this is potentially less worrisome than an oblique injury on the opposite side, since that is usually associated with an avulsion fracture (a piece of bone gets pulled away when the muscle that attaches to it tears, most commonly on the 11th rib) in pitchers. The fracture component alone can take up to six weeks to heal and is part of the reason that these injuries are slow to resolve. If Hoffman has a more minor muscle strain, the time frame should be shorter. On the other hand, the hope is there's not a more sinister problem underlying the muscle strain (sometimes there can be a rib stress fracture underneath the affected area). At this point, it appears Hoffman's injury is of the less serious variety since he already is playing catch.

Nonetheless, even the Brewers acknowledge that this is an early step as Hoffman has yet to throw from a mound, which places far more demand on the trunk. Hoffman will begin the season on the DL, retroactive to March 27, to allow him time to work his way up to game shape. Being a closer, he requires far fewer innings before he is game-ready, yet still needs assurance that he can throw at that level without aggravating the strain. And then there is the added risk of recurrence in-season. Hoffman should still be able to deliver the goods when healthy this year; the question really becomes whether he will be able to maintain a healthy status over the long haul.

John Lackey, SP, Angels
Strikes: Two

The Angels must be wondering just how many more problems their starting rotation can handle … and the season hasn't even started. The latest member of the Angels' pitching staff to succumb to the injury bug is Lackey, who was shut down March 22 after feeling tightness near the inside of his elbow. Persistent soreness in the elbow while attempting to play catch several days later resulted in Lackey undergoing further testing. And despite the Angels' outward optimism, there is reason to be concerned here.

The L.A. Times is reporting that Angels medical director Dr. Lewis Yocum said Lackey will be sidelined for "a couple of weeks" with what is being called inflammation in his throwing (right) elbow. Yocum indicated that although inflammation was visible on Lackey's MRI, the MRI looked better than the one taken at this time last year, when Lackey was suffering from triceps tendinitis. (Lackey ended up missing more than a month to begin the 2008 season with that ailment, but then went on to post a sterling 12-5 record in 24 starts.) The Times reports that Lackey has been given a cortisone shot and is on anti-inflammatory medication while resting his arm. There has been no official timetable issued by the team, but it has become obvious that Lackey will once again begin the season on the DL.

So how worried should we be? Well, it's no secret that elbow problems in pitchers are an undesirable, albeit common, consequence of the position. That being said, the question quickly becomes, "How serious is this elbow problem?" Last year we were not particularly concerned about Lackey's spring ailment, and that turned out to be the right approach. But this second bout of inflammation the very next spring is more bothersome to us, and here's why:

After years of "mileage," the throwing arm does have a tendency to tire out, and early signs of a breakdown are bound to occur in pitchers. That said, rarely do we see the blowout-type ligament failure that leads to Tommy John (ulnar collateral ligament replacement) surgery. More commonly it begins with small structural changes, such as thickened, swollen bursae, bony osteophytes or spurs, looseness or laxity in a ligament (meaning the ligament gets a bit stretched out, like an old rubber band, without showing visible evidence of tearing), and all of these can eventually lead to ligament failure. Exhibit A: Chris Carpenter. This is not to say that Lackey is headed for Tommy John surgery, at least not yet. But the eventual scenario does warrant consideration. He's a pitcher. It happens.

You could look at Lackey's noted durability in the league as the glass being half-full or half-empty, depending on your outlook. Since his rookie year in 2002, Lackey has made at least 30 starts per season, with the exception of the aforementioned 2008, throwing between 3,200 and 3,500 regular-season pitches in each season from 2003 to 2007. That's pretty reliable. But it also raises this question as we head into 2009: Is Lackey on the verge of the warranty on his throwing arm expiring, with small breakdowns ultimately signaling a complete "transmission failure" in the not-too-distant future, or will he continue to perform steadily and soundly with the occasional minor interruption?

The dilemma from a medical perspective is that the question cannot be answered with any degree of certainty. That being said, there is certainly reason for concern. Consider that the Angels have not agreed to the long-term contract that Lackey desires. Although neither side has revealed any specifics, Lackey's pitching age and arm health cannot be separated from the equation.

Stephania Bell is a physical therapist who is a Board Certified Orthopedic Clinical Specialist and a Certified Strength and Conditioning Specialist. She is a clinician, author and teacher with extensive experience in the area of orthopedic manual therapy and sports medicine.