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

Compartment syndrome is the result of the tissues in one of the soft tissue limb compartments being deprived of sufficient blood flow due to the pressure in the compartment overwhelming the pressure in the vessels trying to bring blood in. The local tissues can suffer necrosis and die with high levels of pain if treatment is not quickly engaged. The calf and the forearm are the commonest body parts to suffer this as the muscle groups are wrapped up in relatively inextensible compartments bounded by bone and fascia (firm connective tissue). The firm nature of the compartments makes any pressure build up within them potentially dangerous.

The most common cause of compartment syndrome is a fracture of the tibia but there are other potential causes which include tissue crush injuries, tight dressings and plasters, other fractures and damage to blood vessels. If the syndrome develops the signs and symptoms are a loss of feeling in the area, loss of pulses and loss of the ability to move the limb. Surgical decompression is the primary form of management for diagnosed compartment syndrome. Potential complications include kidney failure, breakdown of muscle tissue and permanent contracture of the forearm muscles.

A traumatic event is the most common precipitating factor for compartment syndrome in the acute mode, but enthusiastic performance of exercises can show measureable increases in the pressure in a compartment, leading to a diagnosis of chronic compartment syndrome. The nerves and muscles are damaged by the acute loss of blood coming into the compartment due to the pressure gradually rising inside an inextensible area. Irreversible tissue damage can occur after the rapid acute onset of compartment syndrome without prompt management.

Shin splints in athletes have been regularly confused with chronic compartment syndrome, with the pain often on both sides and occurring after a particular period of exertion. The criteria for this condition vary in various pursuits and the abnormality can now be sought by pressure measurements. Open tibial fractures give the highest levels of compartment syndrome, with closed tibial fractures being much less risky for this condition. Vascular injuries may also precipitate compartment syndrome but vascular surgeons typically perform decompression at the time of repair if required.

If compartment syndrome is going to be present there have to be either internal or external reasons for the heightened pressure in the limb segments. Outside contributing factors can be clothes which are too tight or similar dressings or plasters. Internal factors may be many and cover tissue oedema secondary to crush injury, internal bleeding, fractures and even doing too muscle building. The pressure levels exceed the blood pressure and this starves the nerves and muscles, allowing muscle tissue death with chemical changes attracting large amounts of water into the areas, further increasing the pressure. Arterial blood flow can be fully compromised eventually.

The elevation of pressure in the leg compartments needs decompression to be performed quickly or with a delay of six or ten hours there will be widespread tissue and muscle death and significant nerve damage. When muscles suffer damage this results in the release of myoglobin into the bloodstream which can engender renal damage which can be fatal. During exercise there is a volume increase in the muscles, raising the compartment pressures during the chronic type of this condition, keeping the levels high between muscle action and compromising blood flow. Muscle cramps can then occur as they do not get enough blood.

Diagnosis of acute lack of blood to a limb can be indicated by limb pallor, pulse loss, pins and needles, pain and coldness of the leg, however these signs are not reliable in terms of diagnosis in clinical practice. Presentation may be of unexpectedly elevated levels of pain not seemingly related to the injury level, with an aching, deep pain which is worse on muscle stretching. On examination of the limb it should be clear whether there is any likelihood of internal tissue damage. Sensory testing can be helpful as pressure shows more obviously in sensory nerve function.

Fasciotomy is the definitive surgical treatment for compartment syndrome, a cutting into the individual muscle compartments to allow the pressure to dissipate outwards and decompress the areas. The wounds may be left open for some days until the pressure subsides and the tissues recover.

Jonathan Blood Smyth is the Superintendent of Physiotherapists 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 Leeds 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

Groin injuries are common in all forms of sporting endeavour, especially those in which a forceful inward movement of the hip occurs, known as hip adduction. Typical sports where this injury is more common are swimming, football, skating and hockey. Groin injuries may make up five percent of all injuries in football (soccer). Groin pain in younger people such as children and adolescents and in women can be due to more serious conditions than a simple groin sprain and should be investigated and referred on appropriately.

Children with hip pain and a limp should be thoroughly investigated as the possible diagnoses include septic arthritis, a slipped epiphysis of the upper femur, Perthe’s disease and avascular necrosis of the femoral head. Such conditions require the urgent attention of an orthopaedic surgical specialist. As pain can be referred from the hip to the knee region it is important for the surrounding joints to be assessed in the examination. In adolescent athletes the growth plate at the hip is a weaker area and may be involved in traumatic injuries.

The hip is the largest joint in the body and has an extensive range of motion. It is vulnerable to damage due to its weight bearing function and repetitive activities performed. Stiffness of the hip joint may be present some time before the incidence of a groin strain and a strain may occur more readily in the presence of reduced range. Acute groin injuries such as tears, strains or sprains of the muscles and tendons occur with forceful adduction of the hip, a movement towards the midline, or if the splits occurs accidentally. Chronic groin injuries present in activities which typically overuse the muscles, such as breaststroke and running.

A groin injury can be difficult to assess as the pain areas and the type of pain described vary and can be vague. There are many medical diagnoses which can be responsible for the symptom presentation of groin pain and these need to be kept in mind. Acute injuries are common and the most prevalent is the typical groin strain, a strain of one of the many muscles running from the pelvis to the femur, maintaining the femur in the centre line under movement. Likely injuring activities include sprinting, kicking, doing the splits, running and changing direction. Sharp groin pain with some thigh radiation is typical.

The junction of where the tendon and the muscle meet is the main region of injury with bleeding from the locally ruptured muscle fibres. The formation of fibrous tissue followed by scar is the method of healing, leaving the area vulnerable to repetitive injuries, with older sports people being at higher risk than younger athletes. If the injury is severe, part of the bone can come off with the tendon, causing an avulsion injury with surgical repair being required at times. Conservative treatment is the standard management with physiotherapists employing exercise, rest and ice.

The adductor longus, one of the muscles in the adductor group of the inner thigh, is the main site of injury. The area of the junction between the tendon of the muscle and the bone is the most vulnerable spot. Muscle belly injuries can be treated relatively simply by graded stretching once the pain begins to settle, strengthening and getting back to normal function. Injuries to the tendon-bone junction need slower management with rest until there is a reduction in pain, graded exercise towards stretching, graded strengthening, and return to functional sporting activities.

Other possibilities for the diagnosis of pain in the groin region include abdominal hernias, often not diagnosable by physical examination, managed conservatively to start with and then if necessary with surgical care. High energy physical events may cause fractures around the hip although older people may fracture with relatively trivial force. Severe pain and limitation of hip movements and gait should be noted and referral made if needed. Sporting activities which involve repeated impacts such as running can cause stress fractures of the pubic rami or the neck of the femur. Other conditions to consider are avulsion fractures if pain onset is quick and inflammation of a bursa.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Oxford. 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

An acute wry neck is a condition characterised by sudden onset of severe neck pain accompanied by an involuntary contraction of the neck muscles which leads to an abnormal head posture being maintained. The abnormal posture or torticollis is a symptom of the underlying process and can have a number of causes, but the cause discussed in this article is acute mechanical neck pain leading to an acquired torticollis. A common presentation for a patient is acute neck pain and torticollis on waking in the morning, often interpreted as the result of having slept in an awkward position at some point overnight.

Patients report severe neck pain often with muscle spasms and an inability to bring the head to the normal central position. This pain usually settles down in a few days or up to two weeks at most and is managed with painkillers, wearing a collar if required, physiotherapy massage or mobilisations, neck exercise and neck stretching. On examination a patient with torticollis will have their head side flexed towards the painful side and the face rotated away towards the opposite side to some degree. Typical complaints are pain, stiff neck and a limited range of movement, with a sudden onset such as turning the head quickly or drying the hair relatively common.

The first thing a person is aware of is the sudden pain on one side of the neck, often severe and lower in the neck. There may be pain radiating also down over the scapula and out over the shoulder. If a considerable amount of arm pain is present then this should raise the suspicion of a lesion of one of the cervical nerve roots. Nerve root problems are usually somewhat slower in onset but if the symptoms presented on waking this could be the diagnosis. The outcome is very likely to be just as good as the muscle or joint strain which is more common, but recovery typically takes longer over a period of weeks.

On examination by a physiotherapist the patient will be distressed by the severity of the pain and may have found it hard to sleep. They may guard the head by moving carefully to avoid jarring the aggravated structures. The head will be stuck in the typical abnormal posture and any attempt to bring it back towards normal will be met with a significant increase in pain. The posture of the head will be recorded by the physio with ranges of motion achievable and the resulting symptoms. The physiotherapist will take the history including previous episodes and how this one came on, either suddenly or during the night.

It is important to enquire after any arm, scapular, thoracic and shoulder pain. The physiotherapist may need to test the C6 and C7 nerve root reflexes of the biceps and triceps muscles respectively should the situation require this and they may also test the sensibility to light touch of the skin for the same purpose. Muscle strength testing may be omitted due to the likelihood of increasing pain and the probability of an inaccurate result. The physio will include asking the standard series of exclusion questions which allow him or her to conclude the problem is mechanical and not due to medical illness.

The aim of physiotherapy for this neck condition is similar to that for all soft tissue injuries. The first goal is to reduce the pain and inflammation in the damaged tissues and so reduce the resulting muscle spasm which is perpetuating the pain. Anti-inflammatory medications and analgesics may be prescribed as to some extent the pain is the presenting problem rather than some underlying abnormality. Physiotherapists may use ice, immobilisation in a collar and gentle manual traction to attempt to relax the cervical musculature and relieve pain.

Progression on to further therapy techniques is planned once the pain is under control such as neck massage, gentle muscle neck stretches for muscle tightness and mobilisation of the joints. The patient is asked to perform active movements within reasonable pain limits. On restoration of more normal neck ranges of motion and head position the next stage of physiotherapy is to increase the neck muscle strength and endurance so that the person can return to normal.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Cambridge. 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