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Physiotherapy management of knee injuries and knee operations requires a good way of applying cryotherapy to counter the swelling and pain involved. The Aircast Cryocuff gives physiotherapists this option as traditional ways of applying cold are clumsy and not very effective.

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 a large, synovial hinge joint which is vulnerable to mechanical injury and when injured it reacts with an inflammatory process. This increases the blood supply and metabolic rate of the knee and the synovial lining starts to secrete synovial fluid, a process which forms a knee effusion. This is “water on the knee”, a swollen knee with synovial fluid making the knee painful and tight, which can interfere with normal functioning of the knee muscles and cause slow recovery of joint function.

Physiotherapy methods of cooling tissues usually have some disadvantages:

* Providing cold and compression at the same time is very difficult/impossible

* Most ice based methods do not cool the knee effectively

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

* Long periods of cooling are difficult to maintain

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

* Cooling cannot easily be done whilst mobilizing.

Physiotherapy treatment priorities have always tended towards cooling the area to reduce the swelling, but prevention of the effusion by early compression may be more important. However, physios do need to provide cooling along with the compression.

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 Reservoir. This cylindrical bucket is plastic with a lid, is stable, light and holds the water and ice needed for the cuff. Level indicators inside the bucket guide the physio to the correct mixture of cold water and ice. Once full the lid is screwed on the bucket is watertight and can be turned upside down or fall over onto its side without leakage.

* 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.

Physiotherapy Use of the Cryocuff

The knee size of the patient 15 centimetres above the knee determines the size of the cuff needed and then the physio fits the cuff firmly to the patient’s knee with the Velcro. The cuff needs to be deflated and firmly attached to get the benefits of the compression, otherwise the cuff will inflate on the knee and but not squeeze the tissues.

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, editor of the Physiotherapy Site, writes articles about Physiotherapists, 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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A rapid recovery from this operation is typical and patients are unlikely to experience any serious complications. Minor problems are very common after this intervention so patients should be aware of these as well about the more serious complications which occur much more rarely.

What is a Cholecystectomy?

The gall bladder is situated beneath the liver and holds bile in a small sac, bile which the liver secretes. Bile is releases in the gut to assist in the digestion of food fats whenever we have a meal. Gall stones can develop within the gallbladder and can be of various types and sizes. It is common for people in the middle of life or older to have gallstones which are not symptomatic and do not require surgery.

Gall bladder pain and inflammation can be the result of stones in some cases and stones may exit the gall bladder and lodge in the main bile duct which is the major connecting structure between the gall bladder and the liver. This can lead to jaundice, a yellow pigmentation of the skin, as the stones can block the bile duct and obstruct the flow of bile to the gut. This may be an example of where cholecystectomy may be necessary to correct the situation.

Is Cholecystectomy Harmful?

The gall bladder’s function is only to store bile so its removal allows patients to live an entirely normal life in its absence. Long-term complications should not occur after cholecystectomy.

How is a Cholecystectomy Performed?

The gall bladder can either be removed by laparoscopic (keyhole) surgery or by the traditional open operation. Almost all gall bladder operations are now performed laparoscopic ally but in some cases (approximately 5% or 1 in 20) the surgeon will decide at the time of the operation that is safer for the procedure to be completed by an open operation through an incision several inches long. This is most often necessary when the gall bladder is very stuck down with adhesions or too inflamed to allow it to be removed safely by the laparoscopic approach.

Even though laparoscopic cholecystectomy is the intended type of operation, patients should be aware that they may wake up to find that the surgeon had to convert the intended technique to an open operation.

Keyhole Surgery for Gall Bladder Removal

Laparoscopic cholecystectomy involves four small incisions through which special surgical instruments are passed into the body. The surgeon is able to see inside using an instrument called a laparoscope. This is a form of telescope with a powerful light to which a miniature video camera is attached. This projects a clear image onto a TV screen allowing the surgeon to see the inside the abdomen and to find and operate on the gall bladder.

Carbon dioxide gas is pumped into the abdomen to increase the viewable space for the surgeon. The laparoscope is introduced into the abdomen through an incision below the tummy button (umbilicus) and three small incisions are made on the right hand side under the ribcage for the other instruments to be used. The gallstones and the gallbladder are removed through the incision below the umbilicus.

Cholecystectomy via Open Operation

Removal of the gallbladder via open operation sometimes cannot be performed, meaning that an open operation will have to be done. The incision is about four to six inches long below the right cage to allow the surgeon to locate the gall bladder. Then the organ can be removed and a drain inserted to drain off any excess fluid from the abdomen.

Administering the Anaesthetic

The anaesthetic is usually administered by injecting it into one of the arm or hand veins. Laparoscopic cholecystectomy typically takes about an hour and a long-acting painkiller is placed in the wound sites to reduce the pain experienced by the patient when they come round.

To give some long acting pain relieving cover after the operation the surgeon may use a suppository in the rectum towards the end of the operation. For 6-8 hours before the operation patients are instructed not to eat anything, and not to drink for 2-3 hours prior to the event. Mobilisation of the patient can occur whenever they feel well enough to get up and about and with help initially.

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.

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The wrist has a large, three hundred and sixty degree cone of movement facing forwards at the end of the arm, a consequence of the close arrangement of the small carpal bones. Group movements or individual ones between the bones can occur and this allows precise control of the hand, thumb and fingers. The rows are arranged irregularly but in general two of the bones line up with the end of each of the metacarpals. This allows the creation of a line of several joints leading to each finger which enables the separate and flexible movements of the hand.

The wrist joint is placed between the hand and the forearm bones and is made up of a group of eight small bones which occur in two rows with articulations on one side with the radius and ulna and on the other side with the metacarpals. The metacarpals, the long bones in the palm of the hand, run from the further row of carpal bones down to the knuckles where they join the fingers. The metacarpals are arranged in an almost parallel pattern and are long and slim bones, giving them the ability to rotate around each other to some degree and improve grip.The Human Wrist Joint

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.

The heavy use of the hands in manual work such as lifting and moving large objects, manipulating heavy machines and pulling ropes can damage the function of the wrist. High mechanical forces are generated when the hand grips something hard, squeezing the wrist bones between the metacarpal bones and the radius and ulna of the forearm. This can allow a reduction of the accessory movements between the individual wrist bones. The lunate bone can be moved from its position with painful consequences if the wrist is extended with force.

A forced extension movement is most commonly caused by a fall on the outstretched hand (FOOSH), which if severe enough can cause a fracture of the end of the radius and ulna, a so-called Colles fracture. The major injury, typically seen in older women, is the fracture but the fall also sprains the wrist, causing significant soft tissue injury to the carpal region. The bones typically heal well in five to six weeks but the hand may be painful, weak and difficult to use for much longer, secondary to the disruption of the subtle relationship between the carpal bones.

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.

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Osteoarthritis is the most common and disabling joint condition in the world, occurring significantly more for each decade of life that passes and being almost universal in old people. OA develops in many joints but large joint OA typically affects the knees and the hips, causing problems with mobility and independence. As the degenerative process proceeds the joint surfaces become roughened and cause loss of motion, crepitus, pain and loss of muscle strength. Conservative measures are painkillers, a stick, physiotherapy and weight loss, and once these are exhausted then knee replacement is likely.

Medical technology developed in the late twentieth century to the stage that joint replacement has become a common and predictable treatment for severely arthritic joints, proving to give the highest quality of life of all medical interventions. Total knee replacement is now a predictable and very successful intervention with good ten year results and beyond. Knee replacement is becoming a more popular operation than hip replacement and as western populations get older the demand will increase.

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

* Femoral component. This is a steel alloy and replaces the arthritic end of the thigh bone.

* 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.

* Patellar button. This is also plastic and replaces the back surfaces of the kneecap. If this is not replaced then persistent anterior knee pain can be a problem.

Cement is used as a grout to fix the components but a precise and tight fit is more important in keeping them in place.

The physiotherapist then gets the patient up, checking the operative record, reviewing the patient’s medical status and assessing the patient and their leg status. Muscular control of the knee must keep the knee stable while mobilising and epidurals can delay this by knocking out the muscular strength and feelings in the legs. A physio and an assistant gets the patient up walking for a short distance with a walking frame if they are older and with crutches if they are more stable. Operation instructions usually allow weight-bearing to facilitate normal muscle activity patterns and promote venous circulation.

Mobilisation of the patient is the next process in rehabilitation. The physiotherapist assesses the patient’s medical status and examines the legs to decide whether mobilisation is appropriate and safe. The quadriceps must be working well enough to provide some knee stability and epidurals can interfere with this for long enough to delay getting up until the effects have worn off. The physio and an assistant get the patient up and establish a good walking pattern with crutches, or a frame for much older people. Normal weight-bearing is usual and this re-establishes normal stresses through the knee, encouraging circulatory return from the leg and normal muscular activation.

Resisted knee flexion is used to increase range via reciprocal inhibition, the resisted movement causing the opposite muscle, the knee extensors, to relax and allow more knee bend. Resistance is provided by manual technique and by using resistance bands. The scar is best mobilised and freed up by tissue massage daily. After individual work patients move on to gym based work, often in groups, to continue with strengthening muscles using gym balls or resisted rubber bands and dynamic activities such as standing up/sitting down and step-ups. Static bicycling and resisted exercises can be used to increase flexion further and training in joint position sense or proprioception is added.

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 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 Oxford visit his website.

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Instability of the shoulder in multiple directions is moderately often encountered, occurring normally on both sides of the body and is not related to accident or injury. The underlying difficulty is the laxity of the capsule of the shoulder and the deficiencies of these stabilising ligamentous structures. This ligament laxity shows itself in excessive joint mobility in all anatomical directions. Patients may describe joint instability as the shoulder may sublux (partial dislocation) or wholly dislocate from time to time. However, the patient may not suffer such obvious symptoms and complain only of pain.

Conservative treatment is the first line of management for this condition, with physiotherapy treatment consisting of strengthening of the muscular parts of the scapular stability and rotator cuff systems. Once conservative treatment has been attempted and not been successful then consideration can be given to surgery. Surgery can tighten up the shoulder capsule, increasing the strength of the static stabilisers. Typically surgery has been done in open technique but arthroscopic technique is become more prevalent.

The incidence of this instability problem in the general public is not obvious and shoulder instability from accidents is much more common as a secondary effect from shoulder dislocation. The shoulder instability types are classified in various ways and TUBS stands for:

* Trauma involved in the cause

* Unidirectional instability (only unstable in one direction)

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

* Surgery – which is often required

TUBS summarises the typical shoulder picture which results from single or multiple episodes of shoulder dislocation.

The instability type which is multidirectional is given the acronym AMBRI which stands for:

* Atraumatic onset (no injury or accident to explain the onset)

* Multidirectional – the shoulder is lax in all directions

* Bilateral (both sided) shoulder involvement

* Rehabilitation used as the initial management

* I stands for the technical types of operative surgery needed for this problem.

The shoulder is designed for maximum mobility to allow the hands to be placed in a myriad of useful positions, usually in front of the eyes so we can see what we are doing. This mobility is extreme and at the expense of the stability of the joint, leading to instability problems under certain physical stresses.

Thinking about the stability of the shoulder it is helpful to concentrate on a few concepts. The idea of balance is related to the way the head of the humerus centres itself on the socket accurately. The main muscles responsible for maintaining this anatomical alignment are those of the rotator cuff, keeping the joint in line as the larger movement muscles do their actions. If an imbalance or weakness develops in the muscles of the scapula or the rotator cuff then the balance can be disturbed. A cartilage rim around the socket, the glenoid labrum, deepens the socket and the muscles compress the two parts together, enhancing stability.

An upward movement of the humeral head on the socket is undesirable and this tendency is resisted by the compressive force of the rotator cuff and by the curve of the upper socket area. The joint surfaces have some adhesion as they are wetted by the synovial fluid, with air being pressed out of the joint by the tight fit of the rounded ball and the depth of the socket, creating a degree of suction effect to enhance stability. Some amount of negative pressure which develops in a tight joint also adds to the effect. The stability which is improved by these effects is in the mid-range of the joint’s movement, where there is least stability from the ligaments.

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 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 complicated anatomy of the foot is targeted at generating propulsive force for running and walking and at coping with the body weight. The ankle mortise holds the talus firmly and it sits at the top of the main long ways arch of the foot. The medial or longitudinal foot arch is the biggest one, this takes the standing, and moving loads of the body with the spring ligament absorbing and releasing some of the energy involved. The outside, lateral arch is much smaller as is the arch across the front of the foot between the fifth and first metatarsal heads.

The foot arches have a very important role in the function of the foot and without them it would not be the dynamic propulsion system that it is. They absorb the energy and forces involved when body weight is applied to the ground, store it to some degree and release it as the next step is taken. If you watch someone walk with very flat feet and no spring you will be struck by the lack of dynamic movement, the slowness of gait and the lack of balance. Maintaining the health of the foot arches should be an important part of keeping fit and able as we age.

The foot has two functions to perform: to cope with and distribute the weight of the body which is often multiplied by movement and to generate propulsive forces to push off in walking. The foot arches are partly maintained by the calf muscles previously mentioned in an article about the ankle, but also by the muscles controlling the toes. The long flexor muscles of the toes also start in the calf and run under the sole to the forefoot and toes, curling the toes or gripping the ground. The short flexor muscles, which start in the feet and again go to the toes, are known as the intrinsic muscles and work by pressing the toes down into the surface but without bending them.

If the foot hits the ground in a person with a highly functional foot the heel will contact the surface first and slightly on the lateral side. The foot rolls forward as the talus rocks inside the ankle mortise and weight begins to be taken by the arches with the joints and ligaments absorbing the stresses. The weight transfers gradually over to the inside and through the first and second metatarsal heads until the foot pushes off partly with the power of the toes 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 individual foot bones need to be able to all move independently, opening out underneath as the pressure is applied and closing up in the upper surfaces. The bones must be able to adjust themselves as the foot spreads to accommodate itself to the surface, allowing a dynamic readjustment to constant changing ground conditions. If some of the accessory movement range is lost the foot loses some of its plastic adaptability as it becomes a rigid prop for bearing body weight and gives up its comfortable propulsive role.

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

While there is a relationship between psychological factors, pain and disability this is by no means clear and likely to be very complex. These factors have been investigated much more completely for lower back pain and it is likely that the factors which relate to neck pain are individual to that anatomical area to some degree. Chronic neck pain is well known to be associated with psychological distress, with whiplash patients exhibiting mood changes such as depression and anxiety, changes in behaviour and degrees of post-traumatic stress disorder.

Neck pain syndromes and factors of a psychological nature are known to be linked in some way but there is little agreement over how this occurs in practice. It is a natural conclusion that the pain and disability resulting from ongoing neck pain would foster psychological distress but could the relationship run the other way? The levels of pain and long term nature of chronic whiplash do look like the triggers for the psychological distress which is evident in this group. The likelihood of pain and disability becoming chronic has not been connected with personality traits or other individual psychological variables.

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.

Fear-avoidance and pain are likely to have a looser relationship in neck pain syndromes than in lower back pain. Patients with whiplash associated disorder have been shown to have intermediate levels of fear avoidance but that this does not predict how well they do over time as both long term disabled and good recoveries show similar amounts. A whiplash injury is usually the result of a sudden incident such as a road accident and levels of post-traumatic stress disorder have been found in these patients. Within a month of the injury if a patient has a moderate level of this stress disorder then they are likely to do poorly in the long term.

As at least a proportion of whiplash patients exhibit post-traumatic stress disorder so physiotherapists need to be aware of assessment and treatment methods for post-traumatic stress. In the biopsychosocial model disability and pain are linked to the interaction of a large number of physical, biological and psychological factors but it is not wholly understood how this interaction of so many varying factors works. The complicated alterations in the sensory reactions which occur in whiplash patients are present in the early stages both in patients who have chronic pain and disability and in those who do not.

In painful syndromes there appear to be biological changes in the neurological system which are responsible for the hypersensitivity which develops in the sensory systems, although some workers attribute these changes to malingering or psychological changes. However, these factors have been shown not to be of great relevance in the generation of heightened sensitivity in neck pain syndromes. The large amounts of pain stimuli entering from the periphery into the central nervous system is recognised as the trigger for the hyperalgesia present in neck pain, with a more limited role for psychological factors.

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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The tibial plateau is the flat, expanded top of the shin bone or tibia which makes up the lower half of the knee joint. It is a very important part of the body for load bearing and any disruption of this area can cause abnormalities in alignment of the knee, knee stability and movement especially weight bearing and walking. Early recognition and treatment of this injury is vital to avoid the potential disability which could ensue and the longer term consequences of knee arthritis. More than half the sufferers from this fracture are over fifty years of age.

A large group which suffer this type of fracture is older women who already have some degrees of osteoporotic change in the area. Younger people with this presentation more likely result from more high energy events. The usual way these fractures occur is for a sideways force to be applied to the knee (often in a knock knee direction) while the knee is weight bearing with a downward force also applied. The lateral condyle (most commonly) is then squashed down by the large femoral condyle on that side. Sports injuries and falling from a height can result in this injury but it is much more common secondary to a road accident.

Pedestrians who are hit by the bumper of a car in slow speed events make up about a quarter of this patient group as the bumper is at the right height to apply the required forces. Sporting events such as horse riding or falls from a height can also cause this type of fracture. The levels of energy involved in the precipitating events can make a significant difference to the types of fracture which result. Lower energy events more typically cause depression fractures whilst the result of a higher energy occurrence is more likely to be a splitting fracture. The complex nature of these fractures has resulted in many efforts at classification, with Schatzker and co-workers’ now accepted.

Assessment of the patient will not only include the state of the bone but the condition of the soft tissues which can also be damaged, the blood vessels, nerves and muscles. Tibial plateau fractures are accompanied in about 50% of cases by damage to the knee menisci (cartilages) and the cruciate ligaments which may require surgery. The medial collateral ligament, the ligament on the inside of the knee, is more vulnerable to damage due to the incident forces being more typically on the outside of the knee in a knock knee direction. Medial plateau fractures result from bigger events as the bone is stronger on that side, with more frequent soft tissue problems.

Surgeons may be happy to accept a range of fracture displacement and pursue conservative or non-operative management in these cases. Lifting the depressed plateau and securing bone graft underneath it may be required if depression exceeds 5mm in depth. Open fractures, where a wound is continuous with the fracture, mean that surgery will be needed, as it is also if the blood supply has been compromised by vessel damage or if compartment syndrome has developed in the lower leg. Less severe fractures can be conservatively managed and if there is severe soft tissue compromise then surgery may have to be postponed.

On establishing the diagnoses the management plan can begin and this includes treatments aimed at limiting swelling and inflammation such as keeping the part still, resting, elevating the leg and compression of the area. Debridement, the surgical removal of any dying or dead tissue, is essential to ensure the well being of the remaining healthy tissue. Compartment syndrome, where higher and higher pressures develop in the leg compartments, is an emergency for which fasciotomy (surgical release of the tissues) is indicated.

Treatment of fractures of the tibial plateau is aimed at restoring the stability of the knee joint, its correct alignment and anatomical relationships of the joint along with full movement in the knee so the knee will function well, is painless and will not suffer arthritic change. If the joint is unstable then surgery will have to be performed, holding the fragments with as little movement as possible. In younger patients with good bone quality then internal fixation may be successful, however older patients with poor bone quality may need to be functionally braced or have total knee replacement.

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

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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.

Impingement is often secondary to an acute ankle sprain where the person stands on something uneven or puts their foot into a hole in the ground, forcing the foot over into a downwards and inwards movement with the weight of the body. Anterior impingement occurs at the front of the ankle and posterior impingement behind, with another lesion type involving the connecting joint between the fibula and the tibia just above the ankle joint proper. An anterior blocking feeling is often reported by patients with this impingement as they try and get the foot up in the ankle. Moving the ankle into dorsiflexion with weight on it can bring on the pain.

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.

If the surgery is more extensive then patients may be given elbow crutches to protect the ankle joint from full weight bearing for up to two weeks, and they may also wear an ankle brace to reduce joint movement. Once settled to some degree the brace is removed and physiotherapy commenced with encouraging of the ranges of movement of the ankle joint and the foot. Ice and ultrasound may be used to help control pain and inflammation. As the ankle improves the physio will progress to more active exercises without great weight involved, such as cycling on the static bike. Further progression involves weight bearing work to improve joint position sense, coordination, balance and strength.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, 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 shoes in which we encase our feet in almost all circumstances may be partly to blame for some of the foot pathologies we experience. The unstable ground surfaces we now encounter much less often were the normal environment for the feet to evolve, gripping the ground and stressing the foot’s small muscles. Now most of our surfaces are flat and smooth and with the foot in a shoe with a flat smooth sole, the foot has a much less varied and challenging job to do of coping with what is underfoot. As the foot has been deprived of its natural environment its muscles, the foot intrinsics, weaken.

The arches of the foot and the function of the toes alter as the intrinsic muscles of the foot weaken as the toes lose the ability to hold themselves straight when gripping the surface. Due to this they start to bend or claw, and as this progresses the muscles which extend the toes can shorten in sympathy, drawing the toes up in a flexed position. This takes the pads of the toes away from any possible contact with the ground, obliging them to take force on the tips perhaps. Overall the foot becomes less functional and the arches decrease in height.

The main arch along the inside of the foot can suffer a loss of strength and height, sometimes brought on by the inward rolling of the foot in gait, causing a stretch to the ligaments underneath the joints of the arch. Stretch of these tissues over some time can produce aching and pain in the foot arch on standing and walking. The transverse foot arch, the less obvious arch across the front of the foot, can collapse down as the small muscles weaken, leading to the bodyweight being applied to the underside of the second metatarsal head.

Having less padding under it, the second metatarsal is less equipped to manage the weight in standing, and people often feel like they are standing on a pebble under the ball of the foot. Hard skin areas known as calluses can develop over this area and are an indication that weight is being taken under the head. High heeled shoes can worsen this condition as the toes are typically crowded together as they are unable to push off in this position and the raised heel area moves the body weight forward over the forefoot.

Bunions are a common deformity of the forefoot, with the joint between the first metatarsal and the big toe enlarging and the big toe migrating towards the smaller toes. As people report their relatives may have this problem there is some likelihood of a family trait. The joint itself can develop pain and cause space problems within shoes due to its position and that of the toes. The foot can gradually change from the springy and responsive part to a static and non-dynamic support for the body weight with consequent functional loss.

Severe bunions are not wholly to do with the joint between the first metatarsal and the big toes but there is also a degree of abnormality in the angle of the first metatarsal which moves towards the inside. This accentuates the deformity. Orthopaedic surgeons have a variety of operations available to correct severely painful feet, with osteotomy of the first metatarsal a common intervention to realign the relationship between the toe and the metatarsal. Most of these operations are now done as day cases provided post-operative pain is not too great and patients can mobilise non weight bearing (hopping) or weight bearing on their heels for six weeks or so.

The assessment and treatment of foot abnormalities is which are not severe enough for consideration of operation are often performed by specially trained physiotherapists. They can analyse foot problems and suggest a variety of already made orthotics such as supportive insoles, correcting hind foot posture and restoring normal alignment of the foot arches. Physiotherapists will also give exercise therapy to strengthen the foot intrinsic muscles and attempt to maintain the integrity of the foot arches.

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 Nottingham visit his website.

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