Back Pain Articles

Human populations are ageing across the world, particularly in developed countries such as the USA, Europe and Japan, with some developing countries such as China set to follow them over the next decades. This will place a large burden on physiotherapy and medical services as countries struggle to cope with steadily increasing levels of osteoarthritis (OA), an age-related degenerative condition. OA is responsible for significant levels of medical expenditure, disability, pain and work loss and provision of services such as joint replacement will be a challenge. Quality of life improvements after medical interventions vary but for joint replacement are some of the highest of all medical procedures.

Hip replacement has a long history but the 1960s saw its development into a reliable procedure, with modern developments making it a predictable and very successful treatment for hip osteoarthritis.

In surgery the degenerative joint is excised and artificial components of alloy steel and plastic are substituted. The hip joint ball is removed and the socket cored out in preparation, the new ball and stem is inserted into pressurized cement in the femur and the new cup is pressed into cement in the socket. The two materials, steel alloy and ultra high density polyethylene, ensure very low friction in the joint similar to the original and contribute to low wear and long life of the joint.

Conservative treatment is always instituted initially but if the joint degeneration becomes severe then joint replacement is the remaining option. The surgeon removes the osteoarthritic joint surfaces and replaces them with new components which are made of steel alloy and ultra high density polyethylene. The ball of the hip is replaced by a metal ball and stem and inserted into pressurized cement in the femoral canal. The plastic socket is pushed into the cement in the prepared socket to complete replacement of the two surfaces. Using the two materials, very slippery plastic and highly polished metal, ensures very low joint friction and a long functional life under load. The physiotherapist will review the patient’s medical notes for their post-operative instructions and medical status and then assess the patient’s respiratory and lower limb function.

The patient continues with buttock, hip flexion, quadriceps and foot exercises regularly to encourage normal limb muscle function and help circulation. They take regular analgesia to reduce pain and assist in their ability to mobilise. Once safe they can mobilise independently at least three times a day to have a walk, go to the toilet and wash and dress. Sitting is encouraged as long as the chair is not low and they are not permitted to put their legs up when sitting.

Physiotherapists routinely teach and correct patients’ gait after hip replacement to improve joint movement, muscle strength and a normal walking pattern. On getting a patient up initially the physio will teach the “step to gait”, instructing the patient to place the crutches forward at first, place the operated leg between the crutches then following it by stepping to it with the unoperated leg. This technique is steady but slow and used when safety is key, and the next progression is to a “step through gait” where the unoperated leg then moves through past the operated leg into a more normal gait. The most advanced gait sees the operated leg and the crutches moving together at the same time and gait approaching normal.

Once they return for their follow up appointment at six weeks after operation patients have often achieved a good gait, reasonable hip strength and returned to some activities of daily living. The physio may advise a stick if they are unsteady, slow or older, and they can gradually regain their previous abilities provided they observe the precautions to prevent hip dislocation:

* Avoid crossing the legs in sitting.

* Weight bearing on the leg and rotating the body weight is unwise.

* Don’t flex the hip suddenly or above 90 degrees, such as by sitting in a low chair, sitting down too fast, crouching or leaning forward quickly to the feet.

* If an infection develops, for example chest, teeth or bladder, then the doctor should be informed as infections can settle in an artificial joint.

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

Osteoarthritis is a time related joint degenerative condition, the incidence rising rapidly with age, making it the commonest arthritic condition in the world. It develops in various joints in the human body and in some people it particularly affects the large weight-bearing joints of the hip and the knee. As the joint surfaces deteriorate the joint becomes painful, crunches, loses range of motion and becomes difficult to walk on. When conservative measures are not helpful, such as physiotherapy, analgesics, walking aids and weight loss, then knee replacement is considered.

Total knee replacement is one of the most successful medical technologies with the highest quality of life improvements of any medical intervention, a distinction it shares with total hip replacement. Knee replacement has matured from an experimental procedure of uncertain long-term outcome to a predictable and very common operation with very good results at ten years or more. As western populations age knee replacement is overtaking hip replacement as the most commonly performed joint replacement.

Metal and plastic components are inserted to replace the degenerative joint surfaces of the knee. In knee replacement these consist of four items:

* The metal femoral insert to replace the lower end of the femur which is the top half of the knee.

* The metal tibial insert to replace the tibial surfaces, the lower half of the knee.

* The plastic insert, made of ultra high density polyethylene, is placed between the femoral and tibial inserts.

* The patellar button is also of plastic and placed on the back of the kneecap to replace that surface.

The components are fixed in place using cement which acts as a grouting material rather than sticking anything. Knee replacement surgery causes weakness of the knee muscles, pain, inflammation and joint swelling, all important problems which the physiotherapist needs to treat promptly. Physios in hospitals often use Cryocuffs to provide cold therapy and compression which reduce the knee effusion and the post-operative pain. Analgesia is encouraged regularly and the physio teaches muscle activation of the quadriceps and knee flexion hourly to get the joint moving. Restoring the muscle control of the knee and gaining joint range of movement is the initial goal of the first few day of therapy.

Once the operation has been completed the physiotherapist must treat the consequences of the operation to ensure a successful outcome for the patient. Surgery causes pain, swelling, inflammation and muscle weakness and much of the early physiotherapy is targeted towards this. Initially the physio can use a Cryocuff, a refillable pressure cuff fitted closely to the knee, to reduce the swelling and to provide cold therapy over an extended period, reducing the pain and facilitating muscle action. Taking the painkillers regularly and static quadriceps exercises are encouraged hourly to re-establish muscular knee control and gentle knee flexion exercises to get the knee range of movement going.

Next the physiotherapist assesses the patient for suitability for their first mobilisation, checking the operation note, the patient’s medical observations and the condition of the legs themselves. The operated knee has to have enough stability to safely weight bear, as an epidural can cause profound loss of muscle power and prevent safe mobilisation until the drugs wear off. The patient is mobilised into standing by the physio with an assistant and encouraged to walk a small distance with elbow crutches or a Zimmer frame for more elderly persons. Operative protocol usually encourages normal weight bearing through the new knee as this helps restore normal patterns of muscular activity and improves circulation.

Outpatient physiotherapy aims to restore normal muscle power and function, joint range of motion and regain functional abilities. Initial exercises include knee hangs for full passive extension (very important for normal knee function), inner range quadriceps to restore active extension to full range and knee flexion to increase range. Resisted flexion over the edge of a bed helps the quadriceps relax by reciprocal inhibition and allows increases in flexion range. This can be manually resisted by a physio or performed against a spring or Theraband. Massage to the scar area is also useful to mobilise the scar and free up the tissues.

Further rehabilitation is more likely to take place in the gym, concentrating on functional activities such as moving from sitting to standing and step ups and strengthening work with Theraband and the gymnastic ball. Work on range of motion will continue using resisted exercises and static bicycling and patients can usefully work on proprioception using the wobble board and other balance related activities. Proprioception is the normal ability of a joint to sense its position in space and this is very important for normal activity and safe walking. Normal gait patterns are encouraged and abnormal patterns corrected.

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

Knee injuries and the management of post-operative knee conditions require physios to apply cold therapy to the joints to control knee effusions and pain. This is difficult to do with traditional methods but the Aircast Cryocuff is a flexible and efficient device to achieve effective cryotherapy and compression.

Knee injuries are very common in sports and vigorous activities and their acute physiotherapy management is very important for a good outcome and a speedy return to normal activities. Typical knee injuries and conditions managed by physiotherapists include meniscal tears (cartilage tears), medial collateral ligament damage, lateral collateral ligament damage, anterior cruciate ligament tears, patellar dislocation, total knee replacement and capsular injury.

The knee is the largest synovial joint in the body and when the joint is damaged it responds by becoming inflamed, increasing the metabolic rate of the tissues and secreting large amounts of synovial fluid into the joint. This can lead to a knee effusion, a large and tight swelling of the knee, at times called “water on the knee”. An effusion can be painful in itself and it inhibits normal muscle function, thereby interfering with muscle action and joint recovery.

Normal methods of applying compression and cooling have several difficulties:

* It is difficult or impossible to provide both at once

* Applying ice to the knee does not provide effective cooling in many cases

* Ice application carries the risk of ice burn by overcooling the skin

* Long periods of cooling are difficult to maintain

* Cooling is difficult to keep up over long periods

* Cooling cannot easily be done whilst mobilizing.

Cooling is always thought to be the main aim, but however as research has shown that management of the acute knee should start with compression instead, pain and inflammation reduction is an important part of the treatment so cold is important too.

The Aircast Cryocuff

The Aircast Cryocuff is a cryotherapy and compression device, designed to be easy to use and to be portable, used in managing post-injury and post-operative inflammation in knees and other joints. The Cryocuff has three parts:

* The Water Bucket. This water/ice reservoir is a plastic cylinder with a lid and guidance markings inside the bucket for the proportions of ice and water to fill for optimal use of the device. The lid is screwed on securely to avoid leakage and the contents can be remixed by simply turning the whole assembly upside down a few times.

* The Hose. The hose from the reservoir to the cuff is insulated and allows rapid clipping and unclipping to and from the cuff.

* The Cuff. This is the business end of the device. It is a wraparound cuff designed to fit the contours of the knee and comes in three sizes.

Application of the Cryocuff by a Physiotherapist

The size of the cuff needed for the patient is measured by the physio 6 inches above the kneecap and then the cuff is fitted snugly to the knee and firmly attached with the Velcro straps. It is important to start with the cuff deflated or the benefits of compression of the Cryocuff will not be forthcoming.

Now the bucket is filled with cubed ice and cold water in the right proportions and the top screwed on firmly to prevent leakage. The hose is clipped to the cuff by pushing the connector into the cuff clip and then the bucket and hose assembly is held up above the knee, allowing the cold water to flow into the cuff by gravity. How high the physiotherapist holds the bucket and for how long has some effect on the tightness of the filled cuff.

The cuff stays cold for an hour or so and the patient can disconnect it from the hose and get on with normal life as able. To change the water the hose is reconnected to the cuff and the bucket put below cuff level to refill the bucket from the cuff, and then the bucket is turned over a few times to remix the water and ice. The process is repeated from the beginning, allowing the compression and cooling to be maintained continuously as the bucket water mixture remains cold enough for 6-8 hours before replenishment.

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 physiothrapists in Southampton visit his website.

The wrist-hand complex is a highly complicated tool which allows for the precise use of the hand and its very important role in human function, with the wrist a vital link in this process. The shoulder and scapula allow crude arm positioning, the elbow allows the distance from the body to be varied, the forearm sets the angle at which the wrist will be positioned and the wrist finishes off the last detail of hand positioning. As the joints get closer to the hand the smaller and more precise their movements.

The wrist itself is positioned between the forearm and the hand and consists of eight small bones known as the carpal bones which are arranged in two rows and situated in between the ends of the radius and ulna and the metacarpal bones. The metacarpals run from the furthest row of carpal bones down towards the knuckles to join the finger bones. As the metacarpals are narrow and run almost parallel to each other this gives them the ability to flatten themselves out to make the hand wide or to curl themselves up to aid grasping, a very useful ability.

This tight grouping of carpal bones endows the wrist with a large range of movement of 360 degrees in a conical shape facing forward. They are able to make individual and group movements to improve the precise positioning of the hand, fingers and thumb. Even though the arrangement is a little untidy the two rows of bones do line up with more or less two bones at the end of each metacarpal separating this from the forearm. The large number of in-line joints created with this arrangement allows a high degree of adaptability and precision of movement.

The manoeuvrability of the thumb is one of the most amazing parts of the function of the hand. The “opposable thumb” that humans possess and which apes do not is one of the defining characteristics of precision movement and control. The metacarpal of the thumb on the outside of the hand is not inline with all the others but rotated inwards, having the ability to rotate further inwards to allow the end of the thumb to participate in grasping with one of the fingers. The thumb has a very specialised joint at the junction of the metacarpal and carpal, allowing the specialised movement.

The movements of the carpal bones can be in unison in small amounts as they move together to allow a movement to occur. As the hands move small amplitudes of movement occur between the individual carpal bones and the carpal rows. The metacarpals are able to rotate around their long axes which allows the palm to be curled into a cupped position. As the palm moulds round to assist gripping it also allows the fingers to align so that they can effectively grip at the correct angle. Any loss of the accessory movements of the carpals and metacarpals can reduce the ability of the hand to function adequately.

Using the hands very heavily such as in gripping and holding heavy objects, hauling ropes or operating heavy machinery can adversely affect wrist function. The longitudinal forces which are generated across the wrist are very high as the hand grasping power is applied, compressing the carpal bones between the forearm and the metacarpals. The carpal bones can then suffer a reduction in the accessory movements possible between them. If the wrist is forcibly extended this may dislodge the lunate bone, one of the wrist bones, forwards and cause pain.

The commonest reason for the wrist to be extended forcibly is a FOOSH or a fall on the outstretched hand, which can result in a Colles fracture which involves the last inch of the radius and ulna near the wrist. The fracture, commonest in older females, is the most obvious part of the overall injury which results also in wrist sprain and soft tissue injury. Five to six weeks will be enough to heal the fracture but there may be weakness, pain and difficulty with use in the hand for a longer period, partly related to a upset in the inter carpal movements.

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

The condition of the shoulder suffering from instability in many different directions is encountered moderately often, happening in both shoulders and unrelated to any physical incident. The lax nature of the capsular bag around the shoulder is the reason that these instability problems are occurring. The high degree of anatomical joint mobility is an indication of the lax nature of the shoulder ligaments and capsule, with patients describing an unstable joint which might dislocate or at least partially do so (subluxate). Obvious joint abnormalities are not always present and patients may just complain of pain.

The mainstay of treatment is conservative management, with physiotherapists working on increasing the strength of the stabilising muscular systems such as the rotator cuff muscles and the scapular stability muscles. If conservative rehabilitation is not successful then surgical intervention can be undertaken to stabilise the more static stabilisers such as the shoulder capsule, tightening up so that stability is increased. Open surgery is the typical technique but arthroscopic techniques are developing rapidly.

How common this pathology is in the overall population is not clear and it is much more common to have instability of the shoulder from traumatic events such as incidents which lead to shoulder dislocation. In this field there are several different classifications, TUBS stands for:

* Traumatic onset

* Unidirectional instability – only in a single direction

* Bankart lesion presence – this is injury to the cartilage rim around the socket

* Surgery – which is often required

A single or repetitive dislocation of a shoulder joint traumatically can lead to the generalised instability problem described in TUBS.

AMBRI is the acronym which summarises the other type of dislocation, the multidirectional form:

* Atraumatic – there was no accident or injury to explain the onset

* Multidirectional – the shoulder is lax in all directions

* Bilateral – both shoulders are typically affected

* Rehabilitation is the first line of treatment with a physiotherapist

* I refers to the technical types of surgery and where they are performed.

The shoulder joint exhibits a high level of joint mobility to allow it to participate in placing the hand in many potential places in space, in front of the eyes so we can see what we are doing. This mobility is at the cost of stability, so the shoulder fails to be sufficiently stable under certain conditions.

In considering what stability of the shoulder means it is useful to think about various concepts. Balance is the concept that the head of the humerus should be centred on the centre of the glenoid socket. The rotator cuff muscles are the main controllers of this positional requirement, allowing the shoulder to be moved around by the large nearby muscles. If the rotator cuff muscles or the muscles stabilising the scapula weaken this can alter the ability to maintain balance. The muscles compress the head into the socket which is made deeper by the labrum, the cartilage rim around the socket.

The upper half of the shoulder socket adds to the resistance against upwardly movement of the head of the humerus which the rotator cuff also provides by its compressive function. Synovial fluid makes the joint surfaces wet and so they adhere to each other to a degree, the convex ball and the concave deepness of the socket combining to push any air out and create an amount of suction force holding the joint in place. A tight joint typically has a degree of negative pressure and this helps it hold together too. These methods of enhancing stability work in the mid ranges of the joint, the parts of the joint range where the ligaments are least effective.

The capsule of the joint is a passive structure which keeps the shoulder movement within certain limits, with the shoulder ligaments being thickenings of the capsule at important areas to resist the forces applied. The most important ligamentous restraint is the inferior glenohumeral ligament; however the dynamic parts of the stability system, the muscles, are also of great importance. Physiotherapists concentrate on rehabilitating scapular stability and the function of the rotator cuff to improve shoulder stability.

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

Ankle impingent involves a patient suffering a painful limitation of their ankle joint mobility from a bony irritation at the margin or a soft tissue lesion. Inflammation of the synovial membrane or the capsule of the joint after the ankle gets sprained several times is a typical history to bring on this sort of syndrome. Repeated ankle sprains can develop into a chronically painful ankle and interfere with walking as well as sporting endeavours. It is not clear how prevalent impingement is but around 10 percent of ankle sprains could develop persistent pain and joint limitation.

An acute ankle sprain which precedes impingement is commonly precipitated by a person stepping into a hole or on to something uneven, forcing the foot inwards and downwards with the body weight on it. Impingent can present as anterior (front of ankle), posterior (back) or as a problem with the tibial and fibular interconnection just above the ankle. Patients with anterior impingement report that the front of the ankle joint feels blocked as they try and pull the foot up. If the ankle is dorsiflexed, especially with some force as in lunging forward whilst standing on the foot, this may point to this diagnosis if painful.

If I there is involvement of the connecting joint between the shin bone and the fibula then it will be very sensitive to firm palpation and respond with pain to malleolar compression. Impingement at the back of the ankle is much harder to establish as a diagnosis with its less clear presentation, with a strong toe-pointing movement of the foot bringing on symptoms potentially. In ballet and fencing people may perform repetitive lunge type movements which can give many small instances of damage to the joint lip which can result in the formation of bony outgrowths in that area.

The investigation of ankle impingement is difficult as the typical methods of imaging lesions may show up little. CT scanning, bone scans and normal x-rays are often reported as normal although there can be bony spur formation on the front lips of the tibia and talus in the case of anterior impingements. Magnetic resonance imaging scanning is used in these cases to attempt to clarify the soft tissue or bony changes responsible.

Ankle impingement is treated initially with conservative methods with typical advice to patients to modify their aggravating activities initially so relieving the stresses on the injured areas to allow pain reduction. To limit the pain and any inflammatory local changes a patient may take nonsteroidal anti-inflammatory medications. Physiotherapy referral can involve the use of local ultrasound, friction massages, mobilisations of the local foot and ankle joints, strengthening muscles and increasing ranges of motion. Ankle braces can be useful for joint stability and to limit joint excursion, with assessment and provision of in-shoe insoles by physiotherapists.

If conservative management of ankle impingement is not successful then surgical intervention may be attempted. The typical operative method is to undergo excision of any bony or soft tissue obstructions and debridement of the local tissues via arthroscopy. Patients can mobilise very soon after ankle arthroscopy provided major work has not been done and be walking about later the same day. It may take four to six weeks for patients to return to their normal activities under the guidance in some cases of a physiotherapist. Results from trials of surgical care in these cases have indicated over 80% of patients fall into the excellent or good result groups.

In cases of more extensive surgery the patient may have to walk with crutches to limit the weight taken by the ankle and wear an ankle brace to limit movement, moving up to bearing full weight over a couple of weeks. At this point the physiotherapist may remove the brace and initiate range of movement exercises to restore normal movement to the foot and ankle. Ultrasound and ice can also be used to control inflammation and pain. With the ankle improving the physiotherapist will move the patient on to exercises without weight such as static bicycling in the gym, and then to exercises on their feet to work on strength, balance, coordination and joint position sense.

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

Flat foot is common in the population and classed either as congenital flat foot which is not a pathology as such and may not give symptoms, and acquired flat foot which develops in adult life from a foot problem. There are many potential causes of flat foot acquired in adulthood which include arthritic diseases, neurological conditions, foot abnormalities and dislocations or foot fractures. In the acquired form of flat foot the most frequent type is secondary to a dysfunction of one of the foot tendons, the tendon of the tibialis posterior muscle. Tendon changes can occur from inflammatory, degenerative or traumatic conditions.

Pathological changes in the tendon of the posterior tibial muscle have been shown to occur more commonly in patients who take steroids, have high blood pressure, are overweight or diabetic and have had injuries or operation to their midfoot. In the group of joint conditions known as spondyloarthropathies the incidence of tendon dysfunction is higher, patients usually having a family history of joint problems. Since older people without particular medical problems can also suffer this condition, degenerative mechanical causes may also be important. In 10% of patients with rheumatoid arthritis this tendon pathology may occur.

Underneath the medial malleolus of the ankle and for a short distance forwards exists a region of limited blood supply which impacts on the tendon running through this area, contributing to an explanation of why degenerative change might occur more readily here. The tibialis posterior tendon contributes to the stability of the medial foot arch which has both passive and active supports. The static, passive supports for the arch include the spring ligament (calcaneonavicular ligament), the long and short plantar ligaments and the plantar fascia. The spring ligament is a support for the talus or ankle bone and stops it migrating inwards or downwards.

The tendon of the posterior tibialis muscle is the most powerful support for the medial arch of the foot. Muscle contraction through the tendon raises the inside of the medial arch of the foot and turns the foot inwards if it is not planted. Loss of this muscle function from a rupture or damage to the tendon deprives the foot arch of its most powerful supporting influence which allows the muscles which turn out the foot to act without restraint. The foot can then undergo three main postural alterations: flattening of the medial foot arch; turning out of the forefoot and turning out of the hindfoot area.

All these changes lead to a loss of the ability of the rearfoot and the forefoot to be a rigid and stable platform which changes the patient’s pattern of gait, making it less efficient. The tibialis posterior muscle has a powerful function and once this is reduced or lost the gastrocnemius and soleus, the main calf muscles, perform their action further back in the foot than normal. The talus or ankle bone is then moved inwards and down, stretching the spring ligament and gradually allowing the medial foot arch to lower as the joints move into different relationships with each other.

Initial patient report on presenting with problems secondary to acquired flat feet is that of a painful and swollen inner border of the ankle region and foot, particularly when on their feet. Patients may mention they have noticed a steady lowering of the foot arch and that they are taking weight on the inner part of the foot now. A reduction in strength and the pain may cause a patient to limp and reduce the effectiveness of push off in gait, with examination of the soles of the shoes indicating the abnormalities in patterns of walking. Foot assessment by a physiotherapist starts with the assessment of the feet and arches in standing.

Observation by the physiotherapist of the heel from behind will allow the visualisation of the two outer toes, if more show then the forefoot is laterally deviated. The physio will assess the angle between the lower leg and the heel to determine the valgus angle of the hindfoot, an important determining factor in foot health. To rise on tiptoe the calf muscle power must be engaged, in a normal foot causing an inversion of the heel.

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

The physiotherapist will typically begin the examination even before the patient takes off any of their clothes by observing the usual posture they tend to adopt. Posture of the shoulders may be slumped and rounded, forcing a stretch from the neck and shoulder blade muscles which might add to the possibility of this syndrome occurring. The physiotherapist will examine the neck’s ability to reach full range of motion and may increase the testing stresses by compressing the neck whilst it is in a combination of movements. This can bring on the symptoms if normal testing does not.

Examination of the nerves and the blood supply to the arm will normally be performed, with the greatest effects on the nerves and muscles supplied by the lower roots of the brachial plexus. If the veins are being compressed in the vascular type of syndrome then patients turn up with swelling and blueness of the arm. If the arteries are the vessels suffering compression then the arm can be pale, cool and without a pulse or with a very weak one. The blood pressure in the affected arm may be reduced by more than 20mmHg compared to the normal arm.

Presentation of the neurogenic form of thoracic outlet syndrome is indicated by the small muscles of the hand showing weakness and perhaps wasting. The ulnar nerve supplies the feeling to part of the hand and this can be involved as it gets its nerve supply again from the lower parts of the brachial plexus. In the last type of thoracic outlet syndrome, the non-specific type, the large number of patients present with less well defined pain symptoms in the whole arm and with unclear and equivocal examination findings.

Thoracic outlet syndrome can be brought on by a large number of neck and shoulder anatomical structures and this is reflected in the numbers of diagnostic tests which have been developed to investigate this problem. A significant problem with these tests is the occurrence of false positive and false negative tests. False negatives mean that the test shows the problem not to be present when it really is and false positives mean the test indicates the tested problem to be present when in reality it is not.

Roos stress test is a typical test for thoracic outlet syndrome, the patient is instructed to maintain their arms in a “hands up” posture whilst opening and closing their hands repeatedly. A positive test result occurs if the arms feels tired or heavy or it elicits the typical symptoms. Thoracic outlet syndrome can be caused either by soft tissue or bony anatomical structures. Obstruction or compression can occur from bony parts such as a growth on the collar bone or ribs or with the presence of cervical ribs. Soft tissue abnormalities include tight fibrous bands or overdeveloped muscles in athletes.

The neck may be more likely to develop thoracic outlet syndrome if it suffers some trauma or mechanical stresses which can combine with any anatomical abnormality such as a cervical rib. If the blood vessels are obstructed then this acute syndrome threatens the health of the arm and surgical release of the compression and blood vessel repair should be urgently considered. The remainder of treatment is conservative including TENS (transcutaneous electrical nerve stimulation), anti-inflammatories and physiotherapy assessment and intervention to the neck and shoulder.

Surgical management continues to be an option in patients whose pain does not settle but the mainstay of treatment remains conservative measures. Physiotherapy review takes in any abnormal muscle balance around the area and any postural abnormality in the thorax, shoulders and neck. If one posture is held for long periods or repeatedly returned to then this may cause dysfunction of neck structures.

Abnormalities of posture can elevate local tension or compressive forces and cause chronic compression of the nerves in the area. Maintenance of muscles in a shortened position can cause them to shorten permanently and then react with pain when they are put on a stretch. The idea of muscle imbalance implies that some muscles are stretched by the person’s function and become weaker whilst others become shorter in consequence and so stronger, perpetuating abnormal function. Management of these conditions starts with patient education as understanding is vital if they are to make long term postural changes.

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

If the neck has been injured or has an overall pain condition, the legs and the arms may exhibit disturbances in sensory reactions even though these areas are not symptomatic. Local hyperalgesia is described as an abnormally high pain response to a stimulus which would be normally painful, and this may be because the local nerve structures in the neck have become oversensitive to incoming feelings. The more widespread reactions are more likely to result from the central nervous system processing differently to normal. The more widespread upsets in sensory systems may help divide whiplash from less serious neck pains.

Whiplash patients have generally higher levels of disability and pain and show more widespread pain on clinical examination. Patients with nerve root problems in the neck and those with whiplash associated disorder (WAD) both share features of sensory abnormality which may indicate that the underlying changes in the processing of pain are similar in both conditions. Another piece of evidence which may back up the role of central systems in these presentations is the occurrence of allodynia. Allodynia is the presence of pain in response to a normally non-painful stimulus such as touching, brushing or wearing clothes.

The abnormalities in sensory mechanisms which have been found in chronic whiplash patients have been shown to be present just after the time of injury. All whiplash sufferers, irrespective of their severity, develop some hyperalgesia to local mechanical stimuli but in milder injuries and good recovery this settles over two or three months. Those with higher pain and chronic symptoms have persistent hyperalgesia symptoms which may not change from the early period. It is known that musculoskeletal pain patients can have their pain thresholds altered by the presence of anxiety or other psychological distress.

It is clear that psychological distress is a feature of patients with whiplash syndrome, with more highly distressed patients having higher levels of pain and disability. However it does not appear that the increased pain sensitivity is caused by psychological distress but that the pain and the distress may be consequences of the heightened sensitivity in the central nervous system. Apart from these findings, investigations have also shown that patients can have an exaggerated pain reaction to cold and changes in the way the blood vessels constrict.

This cold overreaction is a part of the normal injury symptoms if one of the peripheral nerves is damaged and this may support the idea that whiplash injury includes some elements of nerve injury. If there is a nerve root injury in the cervical spine then a cold overreaction response can also be present, possibly linking the underlying pain mechanisms of this pathology with that of whiplash. Neuropathic pains (from abnormal processing in the nervous system) such as burning pain in the neck, sudden pains like electric shocks and cold overreaction have been found in patients with acute whiplash.

Many of the sensory findings in the neck may not easily translate into ways of managing whiplash by physiotherapy. However, if there is only local hyperalgesia in response to mechanical inputs and no other sensory abnormalities, then the local neck structures may be oversensitive due to the injury to the neck tissues. This kind of local abnormality has been shown to react favourably to physiotherapy or other manual therapies. Exercise may also reduce this type of increased nerve reactions and also improves the ways the muscles coordinate, improving the management of neck pain.

If someone has the extra features of neuropathic pain, the overreaction to cold, allodynia and more widespread sensitivity then treatment will have to be much more carefully planned. If the pain is stirred up by treatment this may increase the sensory abnormalities present and make the overall problem worse. More gentle manual and manipulative techniques may be more appropriate in these cases and physiotherapy has been shown to have some effectiveness in managing patients with whiplash.

The presence of the neuropathic symptoms such as overreacting to cold inputs means that there are typically much higher levels of disability and pain and the likelihood of physiotherapy being an effective management is uncertain. Medication for these pains is useful for about 30 percent of patients.

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

As the calf muscles contract and a person rises up on tiptoes to bring the bodyweight over the heads of the metatarsals there is normally an inward deviation of the heel region. This inward deviation will not be present if there is a significant dysfunction of the tendon of the posterior tibial muscle and the patient may not be able to attain the position or can do so in part and with pain. The physio will move on to palpating the tendon insertion with the leg up on a plinth, searching for swelling, pain or tenderness. To test muscle power the physio will resist the inward and downward action of the foot.

The physiotherapist will palpate all along the tendon as its strength is being assessed to check it is not ruptured or deficient and then straighten the knee and measure how much dorsiflexion is achievable, typically twenty degrees or so. If the deformity has been present over time and the foot held in an out and down position then this movement can be lost as a tight contracture develops in the joints. This can also occur in the forefoot joints and the physio will move down to check this after the ankle area. Treatment may be appropriate if the patient is having difficulty with walking, managing shoes, pain and deformity.

A painless flat foot with relatively normal walking in regular shoes perhaps with insoles may be sufficient management for this condition. The conservative treatment of more acute dysfunction involves resting the area, anti-inflammatory medication, orthotics, braces and physiotherapy. Elderly people, who do not put high stresses through this area, may be successfully managed in this way without operation. The initial acute stage of this problem is indicated mostly by local pain, with a plaster of Paris cast an appropriate treatment for acute tendon inflammation. Weight bearing may be permitted if pain is not an issue.

Settling down of the inflammatory and acute phase permits the use of in shoe orthotics to maintain foot posture and a referral to physiotherapy to increase joint ranges of movement and develop increased strength. The rear foot posture can be controlled more precisely if a flexible and painful dysfunction develops by using an ankle foot orthosis or AFO. The next stage of dysfunction, an increasingly rigid deformity, can be managed by more extensive and customised bracing which can extend to above the knee. Such conservative forms of management are the choice for individuals who demand less physically from their feet.

The initial surgical management of the more acute phase of this condition is done by a release of pressure from opening up the tendon sheath and cleaning up any irregularities in the tendon (debridement) and repairing tears. Immobilisation in a below knee cast for three weeks is a typical post-operative management, with the operation aimed at preventing further deterioration of the condition. Once the dysfunction proceeds to a more severe phase there are a very large number of surgical options, little agreed surgical process and a difficult job to ensure a good outcome.

If the tendon is ruptured then the ends may be cleaned up and a repair done end to end, or if the tendon has detached from its insertion it can be reattached to the navicular bone. In more complex repairs the tendons of other nearby muscles can be detached and used to reinforce the function of the tibialis posterior muscle. An osteotomy, a corrective bony operation designed to realign the bony anatomy, can be performed on the heel bone or calcaneum to restore more normal alignment, decrease the stresses on the spring and plantar ligaments and allows any soft tissue operative changes to suffer decreased stresses.

The end result from successful surgery should be the creation of a non-painful foot which can adapt flat to the ground and wear normal footwear. Foot surgery can result in an over correction or an under correction of normal foot posture, with close attention needed to correctly restore the various joint relationships. In the initial phases surgery is aimed at preventing the move towards a tendon rupture.

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 Sheffield visit his website.