hip pain

If you are in the 90% of adults who have a back problem you will know it can be very annoying. There are many different kinds of treatment available like heat treatment, ice treatment, acupuncture and pain killers, however the best method for instant relief is stretching. Stretches and certain exercises for sciatica have shown to have the best reults time and time again. You are about to discover a couple of the most effective exercises that can mean,
* Getting Rid Of Sciatica for Good
* Treating The Cause and Not The Symptoms
* Getting Back To Your Life

Exercises For Sciatica ~Knee Rocking~
The first of the most effective exercises for sciatica is knee rocking. This can be done before you get out of bed in the morning or anytime during the day. Laying on your back with your knees bent at a 90 degrees, slowly rock your knees from side to side. Each rock let your knees get further to the floor until they actually reach the floor on both sides. This is an effective yoga treatment that relieves tension in the lower back.

The Knee Pull
The best exercises for sciatic include the leg grab. This can be done straight after the knee rocking exercise or again anytime on its own. Lay completely flat on your back so your entire body touches the floor and bend one leg so that the knee lifts up. Grab with both hands behind the knee and gently pull towards your chest. Many people forget about their breathing. You must keep it normal. Once you have done one side repeat on the other side and switch for 3 sets.

There are many exercises for sciatica and you will have to try each one to see what works best for you. The two biggest causes for back pain are pore posture and weak muscles and stretching helps with both. If you would like to see a proven routine of exercises that have helped hundreds of people with their sciatica, follow the link below.

Follow the link to get the most effective exercises for sciatica.

A video on the best exercises for sciatica.

Another article on exercises for sciatica, click here!

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One of the most frequent chronic diseases of children and the most common rheumatological condition in this group is juvenile rheumatoid arthritis. This is not one disorder but a group of interrelated disorders which all exhibit inflammatory changes in the joints. The triggering factors for these diseases have not been uncovered and it has proven hard to delineate one particular type of condition from another due to the complex genetic factors. While it is often called JRA, there is a move to standardise the naming of these diseases into juvenile idiopathic arthritis.

Three main divisions of juvenile rheumatoid arthritis can be described, that affecting many joints which is called polyarticular, that involving few joints and termed pauciarticular and a more body wide disease onset known as systemic arthritis. The arthritis is a chronic disease which flares up at times and then goes into remissions, with targeting of the medical treatment towards the induction and maintenance of a remission. Recent advances in the development of drugs have produced the biological agents which are much more effective for arthritic diseases.

The causative factors and how the arthritis develops is not clearly understood, but a trigger such as trauma or infection may start an autoimmune reaction against the joint tissues. This makes the synovial membrane lining the joint enlarge and develops a chronic inflammation, all of these things likely to occur in children who have a genetic susceptibility. Many genes are thought to be responsible for the onset of the disease and how it presents in each individual. There are wide ranges in the incidence of these conditions as the susceptibility to the disease varies along with the different population groups and exposure to environmental influences.

Approximately fifty percent of all sufferers from juvenile chronic arthritis fall into the oligoarticular type with few joints affected, making it the most common type. With a greater number of joints affected by arthritis, the polyarticular type occurs in about a third of patients, with the remaining patients having the systemic form. Juvenile arthritis patients may be susceptible to acquiring a second autoimmune disorder. The significant disability and pain causes psychological distress, problems with behaviour, depression and anxiety. Girls are more likely to suffer from the many joint affected and poor joint affected forms, with equal incidence in the systemic form.

There are two peaks of age occurrence in the many joint affected or polyarticular type of juvenile arthritis, at between 6 and 12 years and between 1 and 4 years. The fewer joint or oligoarticular form peaks between 2 and 4 years, with no particular pattern in age incidence for the systemic form. How the disease behaves over the first six months indicates which form of the disease the patient will be classed as. With a fewer affected joints form there will be four or less involved over this time period. The polyarticular type has five or more affected joints during the six months since onset. The systemic form does not have this pattern but its symptoms are rashes, arthritis and a fever.

If a diagnosis of juvenile arthritis of some form is to be made then the patient should have arthritis of some of their joints for at least six weeks. Stiffness in the morning or after periods when the joint has been kept still is a typical complaint. The start of the disease can be very sudden and dramatic or may come on slowly over some time, with common symptoms including stiffness of the joints as mentioned, joint pain in the day, periods of absence from school and a limping gait. Some patients also suffer from inflammatory disease of the bowel. A child may not always report actual pain in a joint but instead they may just allow the joint to go unused and develop atrophy or a joint contracture.

The type of juvenile chronic arthritis which has a system wide onset has typical symptoms of a fever which spikes regularly once or twice a day with the temperature going back towards normal in between the spikes. This is helpful diagnostically as infections do not behave in this way. A skin rash which lasts a few hours only may appear on the trunk and the limbs, the child may not be well and the larger joints may exhibit pain.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, London Physiotherapy, 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.

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Multiple Sclerosis or MS is a disease of the central nervous system characterised by inflammation and demyelination, the gradual loss of the insulation material around the nerves known as myelin. Sclerosis is the term given to describe the thickened and scarred small lesions which occur in the nerve tracts. The disease is continually active and forms new lesions regularly leading to gradually increasing levels of disability. The most common form of MS is the relapsing and remitting kind, meaning there are periods of worsening followed by at least partial recoveries.

MRI scanning has allowed an important increase in the ability to confirm MS as a diagnosis as the lesions in the central nervous system show up in the scans. No triggering factor or agent for this disease has yet been found, although it is known to be better during pregnancy and worse in the period following birth of the child. MS may be brought on by a number of different factors but only a quarter of MS onsets can be linked to any kind of infection at the time.

There are several different forms of multiple sclerosis which have differing patterns and severities of disease. MS is more common in Caucasian populations and the incidence increases with increasing latitude, in other words how far to the north the individual lives. Genetic inheritance may be important in the risk of getting MS but the environment plays a role somewhere as it is known that moving to a higher risk area before the age of 15 years means you suffer the increased risk of the new area.

2.5 multiple sclerosis sufferers are estimated to be presently living in the world and due to the typical age being a younger group this is the cause of important levels of disability and disturbance of family and economic life. Death is not a direct consequence of multiple sclerosis but there is an estimated reduction in life years of between five and seven, possibly due to the consequences of immobility such as urinary infections. Northern Europe shows the highest incidence of this disease and women present from 1.6 to 2.1 times more often than men in general, although in younger (under fifteen) and older (over fifty) women the proportion is three to one.

The primary and progressive form of multiple sclerosis is more likely to occur in male patients and the relapsing form in female patients. When an attack of the condition occurs it shows up in new symptoms of the central nervous system with symptoms typically occurring over a period of time and in different body areas. Loss of feeling in a body part, optic nerve involvement leading to double vision and sudden loss of muscle power in a limb are all examples of typical attacks. However, there may be no specific attacks but rather a steady deterioration in both mental and physical abilities.

Undergoing an acute attack of MS and then improving afterwards puts the patient in the relapsing and remitting disease group. This is the commonest group but at some time these patients will move to secondary progressive disease and worsen more steadily. In the primary progressive disease form patients worsen more continuously and dramatically, in some cases to overall paralysis. The typical treatment regimes for multiple sclerosis are less effective against the rapid form and it is much more disabling. If the deterioration acquired during the attacks is not recovered in remissions then the form of disease is relapsing and progressive.

The symptoms of MS tend to cover a wide range of abilities in any individual patients but there can be a concentration of symptoms involving the visual, mental functioning or balance and coordination systems. It is thought that at some point in the disease MS sufferers reach a point where the disease worsens more continuously with an indication of neurodegeneration rather than just inflammation. However, one of the characteristics of MS is that patients can present with almost any combination of symptoms or with severe changes in one particular neurological system. Severe loss of mental ability may be evident without much evidence of central nervous system lesions.

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

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The first and vital issue is the correct diagnosis of the injury and its severity as this will dictate the whole course of the treatment and indicate the speed of progression to be expected and the length of time taken until the injury is recovered. Physiotherapy is the main treatment course and the physiotherapist will judge the programme depending on the severity of the injury and how long it is since it has occurred. There are no reliable scientific guidelines for this kind of injury management and rehabilitation so the programme will need to be individually set and adjusted to suit the changing needs of the patient.

There are three initial phases which hamstring injuries can be classified into: the acute phase, the sub-acute phase and the remodelling phase. There is a different treatment plan and strategy for each phase and the time elapsed since injury. The acute stage can last up to the end of the week since injury and the main aims are to reduce the levels of inflammation, pain and swelling secondary to the tissue damage. Treatment normally follows the PRICE system: protection; rest; ice; compression; elevation. Protection is aimed at eliminating any significantly harmful stresses to the damaged tissues, with the treatment options of using crutches to limit the amount of weight on the leg or bracing the knee in flexion.

Rest is the second requirement to protect the damaged muscle tissue by eliminating force through the area although athletes find this difficult to adhere to. Ice is a primary treatment for acute injuries and reduces pain when applied for approximately 20 minutes, with a check after 10 to ensure skin health. Cold inhibits inflammatory changes in the local area by reducing metabolism and so the amount of circulation coming to the area. Compression may be more useful than cold, which is typically used by physios, and controls local swelling, with elasticated bandages applied to the limb an effective strategy.

Elevation is a very useful technique for many injuries and if the part is raised above the level of the heart then the collection of tissue fluid in the part will be reduced. In the hamstrings this is difficult to achieve due to the location of the injury and may in many cases just not be necessary. Once the pain and inflammation have been brought under control the physiotherapist can start doing gently movements either passively or assisting the active movements of the patient. No stretching is attempted at this stage. If someone has a relatively minor injury and begins to feel much better over a few days they should still be carefully managed.

The usual soft tissue healing time is around six weeks, which applies also to minor strains, so care easing back into activity should be observed by athletes along with the progression they adopt. Rehabilitation should include joint ranges, muscle strengthening, balance work and stretching so that the risk of recurrence is reduced. Up to the three week mark is now the sub-acute time frame and there should be much reduced inflammation and pain by now, giving the physiotherapist the chance to begin range of motion exercises and then move onto muscle strengthening.

Prone performance of knee flexions with smaller ankle weights will be the initial process, with increased resistance applied provided the injury does not react. It is advisable to adopt a slow increase in resistance as too rapid a change may cause another injury or a chronic problem. Once the patient can perform strong concentric contractions, i.e. with the muscle shortening, then they should progress to eccentric contractions, where the muscle lengthens during the activity.

The patient starts this process in prone with light ankle weights, progressing to heavier and heavier resistance provided the pain in the injured area is not provoked. The progression of weights should be conservative as too rapid an increase may lead to relapse and a more long term problem. Once the patient has achieved good strengthening with the muscle shortening (concentric contraction) they should be progresses to strengthening with the muscle lengthening (eccentric contraction).

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 Leeds visit his website.

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When a smaller number of joints are affected (the oligoarticular type) there are four or fewer joints exhibiting arthritic symptoms with the larger joints being preferentially affected. Such children do not present as unwell although they may limp when asked to walk. Arthritis may be confined to one hip but if the symptoms are limited to this joint then an alternative diagnosis should be sought as this is much more common, with Perthes disease a typical outcome. Arthritis over some time develops weakness and loss of bulk in the main knee muscles and a knee bend contracture partly due to tightening of the hamstrings. A discrepancy in length of legs can develop if arthritis affects only one leg.

The many joint affected type of disease (polyarticular) is characterised by having at least five joints affected, typically in a symmetrical pattern with the same joints affected on both sides. The child may have a low grade fever and if there are significant limits of joint movement this is associated with weakness of the relevant muscles and decreased normal function. A thorough physical examination of the child is very important for the correct diagnosis of juvenile arthritis as this will indicate where the problems lie and which kind of juvenile arthritis the patient has.

To establish the diagnosis of arthritis on the examination of a joint an effusion (swelling fluid within the joint capsule) must be present along with other likely signs and symptoms such as redness, warmth, pain and limited joint movement. Effusion of a joint may not be apparent in many joints such as the hips but in those cases the limited joint motions and pain will be apparent. The diagnosis may not be apparent initially as the arthritis can come on at the time of the fevers and the rash but it can also be delayed for some months. Liver and lymph node enlargement can be evident with tender muscles on examination. One joint is often affected in the fewer joint form of juvenile arthritis.

In the many jointed polyarticular form of juvenile arthritis the weight bearing joints are typically affected in a symmetrical pattern, as are the small joints of the hand. There may be loss of the articular cartilage with areas of cartilage erosion and in some cases a fusion across the joint, with thickening of the synovial membranes and effusions within the joints. Long term changes in a joint which is arthritic can include partial dislocation, joint stiffness and contractures, bony enlargement and deformities, especially of the fingers. Other findings can be loss of bone stock around the joints and narrowing of the joint spaces due to cartilage loss.

A reduction of extension in the neck may not produce any symptoms but it is important to identify this as it can indicate arthritic changes in the cervical spine which can lead to partial dislocation (subluxation) of the upper neck bones, a potentially dangerous situation. The neck bones can also fuse together along the posterior structures. The jaw joints, the tempero-mandibular joints, may also be affected and lead to reduced amount of growth in the lower jaw with inability to open the mouth as wide as normal. There may also be involvement of the eyes in the inflammatory process.

Management of patients with juvenile arthritic diseases is best accomplished by a multi-disciplinary team which include treatments of patient and family education, occupational therapy, physiotherapy, school functioning and medication. Little success can be gained by using individual treatments on their own. If the patient is reviewed at regular intervals then the medication can be routinely adjusted so that the number of arthritic joints and the stiffness in the morning reduces until there are no symptomatic joints. The multidisciplinary team typically consist of a nurse, occupational therapist, social workers, physiotherapist and a paediatric rheumatologist.

These patients do not routinely require surgical care although steroid injections into some joints can be useful. Knee and hip arthritis in polyarticular arthritic patients may be managed by joint replacement once bone growth has ceased at skeletal maturity. Resting for long periods is unhelpful and patients should be encouraged to keep active for a better end result.

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

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Osteoarthritis (OA) is the commonest joint degeneration condition in the world, resulting in huge amounts of pain and suffering, work loss, expense and disability. Ageing of western developed populations, soon to be followed by some developing countries such as China, will place an increasing burden on medical services as the occurrence of OA rises steadily with age. There will be an increasing need to provide medical and physiotherapy treatment for OA over the next 50 years and for many thousands of people this will involve joint replacement.

Medical interventions can be rated on a scale which calculates the improvement in quality of life which results and here hip replacement comes out top of all treatments. The 1960s saw its development into a standard treatment for hip arthritis but the 21st century has seen the technique evolve into a complex and predictable approach to many hip conditions, with excellent fifteen year plus results. Once conservative treatments have been exhausted due to a worsening joint then joint replacement becomes the standard choice.

It is used to manage a variety of complex hip conditions with excellent outcomes at fifteen years and beyond.

Post-operative physiotherapy consists of reviewing the operation note and the medical observations, assessing the patient and instructing them in breathing and leg exercises. The physio assesses the sensibility and muscle power in the legs to exclude problems such as nerve injury, although an epidural can cause temporary loss of feeling and power in the lower body and delay mobilisation. The next physio job is to get the patient up out of the bed with an assistant, stand and walk them as appropriate with elbow crutches or a frame, taking account of the necessary precautions to avoid dislocation.

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.

A good gait pattern is important in restoring normal walking function, ranges of movement and muscle power and balance. Initial gait taught by physiotherapists is typically the “step to gait”, the walking aids moving forward first followed by the operated leg and then the unaffected leg steps up to the other. This is a slow but stable gait pattern and good for the initial stages. Patients progress quickly to the “step through gait” where the unaffected leg moves past the operated one, and eventually to an advanced gait where the crutches are moved forward at the same time as the operated leg. This pattern is very close to normal walking with a pair of crutches attached.

Six weeks from discharge patients have usually developed a normal gait, good muscle power and have returned to many functional abilities including riding in a car, mounting stairs and normal walking. A stick can be used if the person is elderly or feels they have poor balance or stability. Sensible activities can now be performed as long as the precautions are observed:

* Avoid hip flexion over 90 degrees by not sitting down in low seating, not sitting down or standing up too quickly, not bending over to the floor quickly and not crouching.

* Standing on the operated leg and rotating the body is risky.

* Bending the hip more than 90 degrees should be avoided in such activities as sitting down quickly, sitting in low seats, crouching down or leaning forwards to the floor quickly.

* 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.

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The Aircast Cryocuff is a useful, portable and flexible device for the management of knee injury, pain and swelling. Used commonly by physiotherapists, it can be an important tool in knee injury and post-operative management of knee operations, where the application of cold therapy is difficult with traditional methods.

Sports and energetic activities cause large numbers of knee injuries which need prompt and appropriate treatments from physiotherapists for the best and speediest outcome. Physios manage a wide variety of knee injuries and conditions including: meniscal (cartilage) injuries, medial ligament injury, lateral ligament injury, anterior cruciate rupture, knee replacement, dislocation of the patella and more general injuries to the knee capsule.

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.

Physiotherapy methods of cooling tissues usually have some disadvantages:

* Both cold and compression need to be provided and this is hard to achieve

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

* An ice burn can occur with ice by cooling the skin too profoundly

* Compression is difficult to provide along with the cooling

* Patients have difficulties keeping the cooling going for any length of time

* 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 insulated hose has a clipping system which allows it to be attached to the cuff easily and cleanly.

* 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.

Once the bucket has the correct combination of ice and cold water the top is screwed on to prevent leaks. The hose is attached to the cuff by the clipping mechanism and the cuff filled by gravity by lifting the bucket above the level of the cuff. How tight the cuff is can be controlled by the height the bucket is held and for how long.

The patient is able to disconnect the hose from the cuff and remain mobile while the cuff stays cold for an hour or so, providing the cryotherapy and compression required. They can also do their exercises with the cuff in place. Patients can then reconnect the hose, allow the water to flow back into the bucket then remix it by tilting the bucket before repeating the process of refilling the cuff with cold water. The procedure can then be kept up for six to eight hours before fresh ice needs to be provided for the bucket.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapists in London, 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.

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Observing the patient rising up on their toes as the calf muscle performs the tiptoe action to bring the weight over the metatarsal heads, we should see an inward deviation of the heel area. This will often be absent if the tendon of the posterior tibial muscle is not working well and the patient may not be able to achieve tiptoes, or can do so partially with pain. Palpation around the tendon insertion is the next action for the physiotherapist, searching for tenderness, swelling and pain in the areas. The muscle power will now be tested as the patient is asked to push the foot inwards against resistance.

During the strength test the tendon can be felt to check that it is present all along its route, then the ability of the patient to pull their foot up with the knee straight is measured, typically at least 20 degrees. In flat foot which has been present for some time this movement may be limited with the inward movement, the foot having been in an outward and downward position for long enough to develop tightness, known as a contracture. The forefoot will also be checked for the maintenance of an abnormal position. Treatment will be pursued if the patient has pain and deformity which is disabling, problems with walking or problems managing shoes.

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.

Orthotics can then be used to support the foot once the acute stage has settled and physiotherapy employed to stretch out any tight joint movements and strengthen the muscle groups. As the dysfunction proceeds and the foot deformity is flexible but painful it may be necessary to control the motion of the hindfoot more closely using a ankle-foot orthosis (AFO) of some kind. Later if the deformity becomes more rigid then individually moulded braces, perhaps extending to the knee or beyond, can be employed. This kind of treatment is for patients who are not physically very active, with operative treatment held in reserve.

Surgical treatment of the early acute stage of tendon dysfunction involves opening up the sheath of the tendon to release pressure, a cleaning up of any irregularities in the tendon (debridement) and repairs of tears in the tendon. A below knee cast is used for three weeks after operation and this sort of intervention is thought to prevent the condition from worsening with time. Once the dysfunction becomes more severe the surgical options are many and the choice of which to employ not universally agreed upon and it is difficult to get a very good surgical result.

A ruptured tendon can be trimmed and an end-to-end repair performed, or if avulsed from its bony attachment this can be re-attached to the navicular bone. In more complex surgical procedures the tendons of other local muscles can be used as reinforcements to the posterior tibial muscle tendon, so restoring some of its function. The bony anatomy can also be reshaped by performing an osteotomy and realigning the joint relationships, such an operation on the calcaneum or heel bone aimed at restoring alignment, reducing forces through the plantar and spring ligaments and permitting the soft tissues to endure less stress.

Overall, surgery aims to achieve a painless foot which can adapt flat to the ground and which can wear shoes easily. Surgery can result either in an under correction of the deformity or an over correction and great care must be taken in aligning the many components of an appropriate foot posture. Initial surgery is to prevent the progression of the tendon inflammation to eventual rupture.

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.

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There are two major classifications of flat foot, congenital flat foot which is often asymptomatic and cannot be classed as a pathology, and acquired flat foot which occurs in adulthood secondary to some pathological condition. The causes of adult flat foot are many and include fractures or dislocations of the foot, abnormalities of the foot, neurological problems and arthritic conditions. The most frequent cause of this acquired form is a dysfunction of the tibialis posterior tendon, the tendon of one of the calf and foot muscles. Trauma to the area, inflammation or degenerative changes can all affect this tendon.

In scientific studies changes to the tibialis posterior tendon have been shown to be more frequent in people who are diabetic, overweight, have had operations or trauma to the midfoot and have a history of taking steroids. A higher incidence is also shown in patients who have an arthritic condition in the group of spondyloarthropathies, having a history in the family of psoriasis or joint related inflammatory conditions. A mechanical cause may also be common as older people without any explanatory pathology can also suffer from this tendon dysfunction. Rheumatoid arthritis sufferers may show this in 10% of cases.

The medial malleolus is the bony prominence inside the ankle and just below and in front of this is an area of compromised blood flow in which the tendon runs, which might contribute to the onset of degenerative changes in the tissues of this region. The tendon of the posterior tibialis muscle adds to the support of the medial longitudinal arch of the foot which is actively and passively supported by structures. The passive, static supporting structures are the longer and shorter plantar ligaments, the plantar fascia and the calcaneonavicular or spring ligament. The ankle bone, also called the talus, is prevented from slipping down and in by the spring ligament.

The most important active or dynamic supporter of the medial arch is the tendon of the tibialis posterior muscle. As the muscle contracts it lifts the inside of the medial foot arch and turns the foot in if it not on the ground. If this muscle function is lost due to damage or rupture of this tendon then the foot loses its major arch support and inward turning action, allowing the outward turning muscles to act without opposition. This results in the foot suffering three main changes to its postural balance: the medial arch flattens; the front of the foot turns out and the rear of the foot turns out also.

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.

On observing a foot from behind it is usual to see the two lateral toes on the outside and if more are visible this indicates forefoot abduction. The angle between the line of the heel and the line of the lower leg will be measured by the physiotherapist assessing the foot, indicating the valgus angulation of the heel. Asking a patient with a normal foot to go up on tiptoe will show an internal movement of the heel as the calf muscle contracts.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, 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.

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The pain and other symptoms which are involved in neck problems typically cause functional difficulties which show themselves in complicated limitations of movement and activity. However, the pain and neurological aspects cannot be considered on their own as psychological factors are also involved in the generation and maintenance of neck pain conditions. Physiotherapists need to be able to identify important psychological disturbance so that appropriate onward referral can be made and so that the assessment and treatment can be adjusted in the light of these factors. Psychological factors may in some cases be of crucial importance in how the patient is behaving in response to neck pain.

It is clear that there is an important relationship between pain, disability and psychological variables but this relationship is complex and not obvious. Psychological variables in lower back pain have been much more completely investigated but it seems that the variables in neck pain may be more specific to cervical pain and not the same. People suffering from long term neck pain are known to shown alterations in mood such as depression and anxiety, with patients with whiplash also showing changes in the ways they behave and posttraumatic stress.

While it is well recognised that psychological factors are important in neck pain syndromes, there is no agreement in how they function. It seems logical that the pain and disability resulting from long term neck pain would cause psychological distress, but could it work in the other direction? It looks likely that chronic whiplash pain sufferers develop psychological distress in response to the severe and ongoing nature of their condition. No connections have been found between personality traits and other psychological variables present before the condition with the likelihood of the situation becoming disabling and long term.

If the functional restrictions and the pain levels persist then there is some indication that this also maintains the levels of psychological distress. A poor outcome in whiplash associated disorder has not been shown to be linked to mental ability, self rating of well being, depression or anxiety. Fear-avoidance has been investigated in regard to lower back pain problems and has relevance in the prediction of longer term disability. The idea of fear-avoidance is that the fear of pain and potential bodily damage from an activity impels the sufferer to limit their activities and withdraw from physical situations.

Lower back pain and fear-avoidance have been shown to be closely related but this is not likely to be the case with neck pain. Moderate amounts of fear-avoidance have been found in patients with whiplash associated disorder but no connection has been made between this and the outcome, being the same in people who do badly and those who do well. A sudden incident such as a motor vehicle crash is the commonest reason for whiplash injury and patients exhibit levels of post-traumatic stress disorder. A poor outcome in the long term is associated with patient showing moderate stress disorder within a month of the event.

Physiotherapists need to be aware of the presence of post-traumatic stress disorder in whiplash patients as it is a relatively common occurrence and should be able to recognise, assess and have some therapeutic approach to this aspect of the condition. Pain, distress and disability are linked together in the biopsychosocial model, with the large numbers of psychological and physical factors contributing to the presentation of the patient. How these factors interact to produce the overall outcome is not well understood. The sensory hypersensitivity in early whiplash does not predict between good recovery and poor.

The underlying biological changes which occur in the central nervous system during pain syndromes are thought to be responsible for sensory abnormalities, although some think that these factors are minor compared to psychological ones or that malingering is common. However, there is some evidence that the increased reactivity in neck pains has been shown not to be the result of psychological factors. The barrage of incoming pain stimuli into the central nervous system from the damaged areas is accepted as the cause of increased sensory sensitivity, with psychological factors playing a minor role.

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.

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