The foot’s design is complex and specialised to manage the forces generated by bearing the weight of the body and by the need to propel the body in gait. The talus is at the apex of the main longitudinal foot arch and is held firmly by the ankle mortise. The largest arch is the lengthways or medial arch of the foot which manages the forces involved in moving the body and standing, the spring ligament contributing to this by storing and releasing the energies involved. The outside or lateral arch is less obvious as is the transverse arch at the front of the foot.

The foot would be unable to fulfil its job of dynamically propelling and supporting the body without the arches it is designed to have. The arches absorb and hold the energies as the weight of the body interacts with the surface, releasing the energies as the step is completed. Watching someone walking who has flat and painful feet it is clear that their feet are just platforms, exhibiting a complete lack of dynamism and flexibility. It is important to maintain the health of the arches to keep our mobility at its highest level as the years go by.

The foot is designed to fulfil two main actions: to accept the forces generated in locomotion and generate propulsive forces to effect gait and to manage the forces involved in movement of the body weight which are often greatly increased by motion. Some of the calf muscles, as mentioned in an ankle article recently, function to keep the arches of the feet working but the long flexor muscles of the toes do this also. Originating from the calf and running underneath the foot to insert into the toes, these muscles bend the toes and work by gripping the ground for stability and movement. The shorter intrinsic muscles, originating in the feet and inserting in the toes, bend the toes whilst keeping them straight.

When a person with a normally functioning foot takes a step the first contact with the ground is with the heel somewhat on the outside. As the step continues the lower leg rolls over the talus inside the ankle joint and the foot arches, the joints and ligaments, absorb the energies of weight bearing and movement. Moving forwards and inwards, the weight is borne finally by the metatarsal heads of the second and first toes, with the final push from the toe muscles.

Each moving joint in our body has a degree of accessory movements in it, which are limited and subtle internal movements between joint surfaces which cannot be exhibited in isolation. A normal joint depends to some degree on the accessory movements present within the joint and if these are lost or reduced the joint’s function is compromised. A high number of intricately designed foot bones are packed into a small area, creating the arches, and all these bones have highly functional accessory movements between them.

The foot arches begin to flatten as the weight of the body is passed through the foot and the tension and elasticity of the foot ligaments counteracts this with the strength of the calf and foot muscles. In moving towards push off the foot is aided by the calf muscles contracting as a sling to maintain the arch, the gripping of the ground by the toe muscles and by the energy recoil of the ligaments. The arch varies in height as the walking cycle continues and this means accessory movements between the many arch bones are constantly occurring so that the bones can slide and glide into the required positions.

The independence of movement between all the many foot bones is vital as the weight causes a spreading of the under surface of the joints and a closing in of the upper joint lines. The foot can accommodate to the circumstances which present themselves in a dynamic fashion at least partly to the individual inter-joint movements. The foot will lose some of its flexibility in responding dynamically to circumstances if accessory movement is lost and the foot changes function from an active system to a passive platform.

Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Bolton visit his website.

Tags: Alternative medicine, back injury, back pain, back pain relief, Frozen Shoulder, Health, injury management, pain management, physical fitness, physiotherapists, physiotherapy, Piriformis Syndrome, sciatica

The management of dislocated shoulders is a matter of controversy in the orthopaedic field, with the usual management being confined to a sling for between one and six weeks, with or without a strap around the waist to prevent external rotation. The arm is maintained close to the body with the forearm across the belly, a position known as medial rotation and adduction. This avoids the stresses which would be applied to the joint if it were moved to the side or outwards, known as lateral rotation and abduction.

Recent studies of dislocation in the scientific literature have shown some clues as to how these injuries should be managed. One study involved MRI scanning to show that the relationship between the rim of the socket and the socket itself is best maintained by placing the arm by the side and rotating it laterally 35 degrees. A cadaveric study of shoulders showed that keeping the arm in slight adduction close to the body allowed a reasonable range of motion without disrupting the close approximation of the structures. Lifting the arm up forwards or out to the side (flexion and abduction) disturbed this relationship.

The time of immobilisation is not one of general agreement with three or four weeks in a sling typically prescribed for younger people and shorter periods for older people. A longer period of immobilisation was shown in one study to significantly lower the rates of recurrent dislocation. Another study followed patient with shoulder dislocation for ten years and found no influence of the period of immobilisation on the rate of recurrent dislocation. After the patient is reviewed at the three week period they start their rehabilitation with the physiotherapists.

Initial exercises will include pendular exercises, chosen for their reduced joint stresses due to the patient being bent over and the arm hanging in a relaxed position. This keeps the shoulder joint moving without fear of overstressing the joint capsule. Scapular movements are also performed early so that the shoulder girdle remains mobile and functional. Active assisted movements are the next progression taught by the physiotherapist, allowing the range of movement to be increased whilst reducing joint stresses as the other shoulder contributes much of the force needed.

The risk of dislocating again means that lateral rotation of the joint will be restricted and the range gradually progresses as healing occurs, without ever being strongly stressed as a loss of the end range of this movement may help this joint prevent further dislocations. Restricting the joint from attaining the risk position may reduce the likelihood of it dislocating again. Six weeks is typical soft tissue healing time and patients are then progressed onto performing full active range of motion exercises and also muscle strengthening.

Some patients demand high performance from their joint and need ongoing advanced rehabilitation but should be prevented from pursuing overhead sports for about four months. If the patient has a greater tuberosity fracture (a small bony upper arm area with tendinous insertions) or is an older person then their outcome is somewhat better. Patients may be required to modify their typical activities by limiting overhead actions, avoiding sports which demonstrate high risks and change to lighter physical work.

Overall the incidence of re-dislocation of the shoulder is around 30 percent in non-sporting people but rises to eighty-two percent in those in athletic sports. The age of the patient is however very important in determining the recurrence rate. There is a one hundred percent chance of dislocation recurrence in patients under 10 years old and only zero to 24 percent likelihood in patients who are in their forties. Surgical management may be required should a patient suffer from recurrent dislocation of the shoulder.

The timing of surgical management is not clear although early surgery after the initial dislocation may be advantageous. Studies vary but one showed that after stabilisation surgery via the arthroscope there was a four percent dislocation rate but a 94 percent repeat dislocation rate after conservative treatment. Overall it looks like the recurrence rate is higher for those patients managed by non-operative immobilisation. The level of stability given in operation was better with open surgery but arthroscopic techniques have advanced considerably and this distinction has disappeared.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and physiotherapist in hartlepool. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Tags: Alternative medicine, back injury, back pain, back pain relief, Frozen Shoulder, Health, injury management, pain management, physical fitness, physiotherapists, physiotherapy, Piriformis Syndrome, sciatica