Alternative medicines

Posts Tagged ‘pain management’

Everyone suffers difficulties and adversity of some kind, examples of which are mental illness, disability, pain, illness and stress. Not everything is under our control and we have widely varying ways and success of dealing with these stresses. How content we are with our lives and how effective we are at life management depends on our ability to cope with these events. If we can be realistic and generate a plan for managing then success is the more likely outcome. What happens to us when we suffer setbacks is complex and we need to address several parts of the situation.

Loss figures in many of the challenges we face and this needs to be recognised as many consequences flow from this. We accept without question when we do not have any pain and feel a loss when our bodily comfort is removed. Simple activities are affected such as doing the gardening, getting the shopping and sitting in a restaurant or cinema. As we get older many changes creep up slowly upon us and we may not be happy with these and find them hard to accept. A sudden and dramatic change in our comfort or ability is much more difficult to accept, particularly if we are young or very active.

There are many potential losses such as the death of someone close, losing our job or our role in life, losing our income, breakup of a relationship and the loss of a part of the body. These losses affect and dent our self esteem. Depression is the most disabling mental difficulty in the world and largely caused by a loss of some kind, unless endogenous. Depression causes our brain chemistry to alter so that we think more negatively about what happens to us and interpret our findings in the same negative way. Depressive thinking is important due to the feelings of the person and their actions but also because depression is commonly associated with pain.

We may not be that successful in coping with and coming to terms with these losses. Hopelessness may be the result if we become depressed so we lose the motivation to take the required actions which would ameliorate our condition and situation. Cognitive therapy and antidepressant drugs can be used as required to kick start the improvement process of more realistic thinking and begin generating helpful approaches to our troubles. We can react in an entirely different manner to these challenges by fighting strongly against them.

I’m just not going to let the pain beat me is a very common sentence uttered by pain patients, turning their condition into a competition which pain is not going to win. This strategy is commonly pursued as people try to maintain control in bad circumstances, pushing themselves to keep going with their duties. There is a significant downside here though and that is the very high costs of holding a continuing battle with pain by pushing on, leading to a decline of ability, increasing pain and depression.

Conflict is one of the most important concepts here. The conflict exists between what we think we should be able to do and what we can. We can feel aggressive towards the pain and towards the world which demands things we cannot supply. We can thereby develop a relationship of conflict with others and within ourselves which can obstruct us from generating alternative approaches to our problems and gets us stuck in a rigid behaviour. These problems are all related to not accepting the reality of our situation and we cannot move forward as those actions are not acceptable.

The idea of acceptance is important and should not be mixed up with resignation. In resignation we feel helpless and that we just have to accept everything, thinking that nothing much will change things for the better and we have to put up with the situation permanently in this way. This kind of very negative assessment of the problem will lead most likely towards depression and make it unlikely the person will take actions to get themselves out of their situation. It is undesirable to feel resignation and more functional to learn acceptance and so work at changing the future for the better.

As children we have the great gift of a mobile, strong, well designed and painless spine and it is unusual for stiffness to be an issue as the lumbar spine has evolved to do the job of weight bearing and providing movement. Intervertebral discs separate the spinal vertebrae, allowing more movement in areas where they are thicker and also coping with variable loads. The posterior spinal facet joints limit and control segmental movement, preventing the spine from displacing inappropriately under the shear forces. Strong, balanced and coordinated muscle actions complete the picture.

An acute episode of low back pain inhibits the core stabilising muscles from working well and can cause wasting of them with time. Segmental loss of stability control can make the occurrence of further low back pain episodes at the same level more likely. As time and injuries change the spine, degenerative changes can occur in the facet joints and discs, leading to segmental stiffness and chronic back pain. The force of gravity pushes fluid from the discs by compression and is opposed by a chemical absorption of fluid which is more powerful in lying.

As compression forces tend to be more powerful as time goes on, dehydration of the disc occurs to some extent as it narrows and stiffens. This can be imaged on x-ray but the disc is likely to show changes and painful problems long before the results can be seen on x-ray. A segment is defined as two adjacent vertebrae and the intervening intervertebral disc, an altered disc contributing to an abnormal segment which moves abnormally and pushes abnormal loads onto tissues where they are not designed to take them. Physiotherapists can feel the restrictions in spinal movements which occur when a stiff segment limits segmental excursion.

Protective muscle spasms are common after an injury and this splints the affected area and allows the process of inflammation and healing to get started. With the gradual resolution of the injury and its pain reduction the amount of back spasms normally lessens and slowly normal movements begin to be apparent again. But muscles can remain in muscle spasm in some cases, leading to a stiffened and shortened group of spinal structures which, by this adaptive shortening, leads to the production of shortened and abnormal spinal joints, ligaments and muscles.

Increase of the compression forces through the spine can be promoted by sitting for long periods, leading to increase in the fluid loss from the discs. Discs rely on us repeatedly bending forwards for disc health and nutrition and avoidance of this movement compromises disc wellbeing, leading to an increased potential risk of degenerative change. A weakness in the abdominal muscles and the development of abnormal postures also contribute to these problems.

A typical history is to have an episode of severe low back pain which gradually develops into a segmental stiffness problem. The stiff areas may be present asymptomatically for many years in many individual areas of the spine before one of them develops into a painful segment which causes restriction. Sitting for a long time or spending time bent into flexion will tend to aggravate this condition once established as joints are moved beyond their comfortable limits. The lumbar facet joints become fixed into extension and the whole segment suffers from adaptive shortening, forfeiting its ability to move normally. I have back problems very like this and it can be quite difficult, forcing me to limit heavy or repetitive work or any significant time in flexion.

Sarah Key, a physiotherapist who is well known in the UK, has produced the Sarah Key’s Back Sufferers Bible, a book in which she sets out her views of what is going on in this most common of musculoskeletal syndromes. She does acknowledge that it is hard to bring solid evidence for many of her interpretations but seems to have many good and practical therapy ideas to approach the back pain problem with. She covers the main syndromes which typically occur, giving treatment routines for self management of each one, all of which I have found very useful for my own lower back pain. Now I have something I can do about it rather than accept it as a fact of life.

Non-bony Structures in the Foot

The foot does not consist only of bones but also of tendons, muscles and ligaments. Ligaments are tough, relatively non-elastic straps or sheets which are designed to hold bones together. Ligaments allow the intended movements of the joint to occur and give the joint the stability it requires for normal function. Ligament capsules surround all the many joints of the foot, stabilising these joints and allowing the synovial lining inside them to secrete synovial fluid. The plantar ligament underneath and along the foot arch is the largest foot ligament.

The plantar ligament holds the arch in place to some extent and stores up energy when we are walking to use in the next step, giving us the spring in our step. A strain of the plantar ligament can be sharp and painful in the ligament and have knock on effects due to its supporting role. At the back of the heel is the Achilles tendon, a large and strong tendinous band which is a continuation of the fibrous tissue in the calf muscles, the soleus and gastrocnemius. The calf muscles provide propulsion in walking and running and allow us to stand on tiptoe.

The complex nature of walking has been called controlled falling but is managed easily by the majority of humans. Gait is a repeating pattern of specific bodily movements and when we stand still our weight distribution is even between the front and back of the foot. The outside border of the rear of the heel strikes the ground first as the foot contacts the ground, with weight then transferring forwards and inwards towards the big toe and ball of foot. Absorption of some of the load occurs in the plantar ligament, with the arch flattening by some amount and the foot attaining the position of pronation.

Hitting the ground and bearing weight on the midfoot brings the foot posture towards the outside into supination as the foot rises to push off on the ball and the big toe and the foot leaves the ground. Exaggeration of these postural positions during gait is an example of pathological changes which can occur. The big toes take around 60 percent of the weight being transferred through the foot in walking, and this can be abnormally increased if the foot overpronates and throws weight medially. The opposite tendency is underpronation as the person throws their weight laterally onto the outer foot border.

Problems with Gait

Changes which occur in one bodily area can have distant effects on other bodily regions due to the connected nature of body systems. A typical gait pathology is the antalgic gait, a gait where the body attempts to avoid a painful position or weight bearing posture. One of my neighbours attempts to minimise the forces which are being transmitted through his low back by gliding around smoothly, limiting spinal movement and using his legs almost exclusively to perform his gait. Pathologies can develop in other areas of the body as it attempts to limit forces by adopting an altered gait.

Foot pain does not typically occur in children and adolescents despite the many forceful activities they pursue. However, if a young person describes a pain problem with their feet it should be noted and action taken to solve a small initial problem as opposed to a later much more major one. In the twenties it is uncommon to report any problems with the feet apart from fungal infections and sport and activity related injuries.

Children and adolescents rarely have foot pain even pursuing the many, varied and vigorous pursuits they love to do. If they do report a pain problem it is worth paying attention and getting advice as it’s much easier to fix an early, minor problem than having to cope with a much more difficult one later. During one’s twenties feet typically do not have great problems apart from sporting and other injuries and infections such as athlete’s foot.

Patients recover very quickly from this abdominal operation and it is rare to suffer serious side-effects. Cholecystectomy produces a number of minor post-operative complications so it is important to understand these as well as the rare potential for more critical complications.

About Gall Bladder Removal

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.

Sometimes the stones can lead to pain or inflammation with the gall bladder. In some patients stones may escape from the gall bladder and get into the main bile duct (the main tube connecting the liver to the gut) where they can cause an obstruction leading to jaundice (yellow pigmentation of the skin). In these cases it may be necessary to perform a cholecystectomy (surgical removal of the gall bladder).

Is Gall Bladder Surgery Harmful?

Many people live a completely normal existence without their gall bladders as it is only an organ to store bile. Cholecystectomy should cause no serious long-term side effects.

The way Gall Bladder Operation is Performed

Surgeons can use the more traditional open surgical technique or the more modern laparoscopic or keyhole surgery which is the overwhelmingly more common method but about one in twenty or five percent of operations are through an open incision. This is because the surgeon decides it is safer and the most common reasons for open surgery are because the gall bladder is very inflamed or if it has a lot of adhesions sticking it down to nearby organs.

Although surgeons mostly intend to perform the gall bladder removal laparoscopically, patients need to understand that during the operation the decision may be made to convert to an open operation on clinical grounds.

Keyhole Surgery for Gall Bladder Removal

The surgeon will make four small cuts so that he or she can insert the instruments they will use into the abdominal cavity. The main instrument is a laparoscope, a flexible device which has a small video camera and a bright light attached, allowing a clear view of the inside of the abdomen. This allows surgeons to view the abdominal contents on a television screen, find the gallbladder and guide the operation procedure.

The surgeon needs a good view of the abdomen so carbon dioxide is passed into the cavity to increase the room for manoeuvre. An incision below the umbilicus (tummy button) is used to insert the telescope and further instruments are introduced through three smaller cuts below the right ribs. The umbilical incision is used to withdraw the gallbladder and gallstones.

Open Cholecystectomy

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.

What about the Anaesthetic?

The anaesthetic is usually started by giving an injection into the hand or arm. The operation usually takes about one hour and the surgeon will often inject some long-lasting anaesthetic into the incision sites to try and make the patient as comfortable as possible afterwards.

In addition some surgeons insert a long-acting painkiller in the form of a suppository into the back passage when the patient is asleep. Patients are advised clearly about having no food for about 6 hours before the operation and nothing to drink for about 2 to 3 hours beforehand. After the operation patients can get up as soon as they feel able with a nurse making sure they can manage when they first get up.

Diverticulosis is the medical description for the presence of diverticula in the colon. A diverticulum involves a small pouch being formed as a part of the inner intestinal lining pushes through muscular outer layer of the intestine, leading to a narrow-necked pouch. Diverticula mostly occur in the colon on the lower left side and diverticulosis is the term when many are present in the gut.

Is the cause of diverticula known?

The small intestine is the commonest place for a diverticulum to naturally occur. As people get older the number of diverticula increases as later life is the commonest time for these to occur. Diverticula in the large intestine occur in more than half the people over 70 in Britain while in the world’s rural areas, especially Africa, diverticula occur rarely. It is not known why other areas differ from western countries in this condition but diet may be important as the colon is the processor of dietary fibre present in poorly digestible plant foods.

Fibre rich materials form a much smaller proportion of western countries’ diets compared to the mostly vegetarian other parts of the world. The bulk of intestinal contents maintains the shape of the colon if the diet has the right levels of fibrous material to allow it to function well. Firmer and harder stools result from low levels of dietary fibre and when the colonic walls tighten the reduced contents fail to adequately keep the walls apart. The ring like contractions move and mix the contents along the colon and there can be closed sections where the pressure is much higher than normal, perhaps leading to pouch formation.

Is the presence of diverticula harmful?

We all begin life with an appendix, which is a diverticulum in many ways, and we do not worry about it. In the same way many of us have diverticula projecting from the wall of our colon. We do not know we have them and they cause us no trouble. However, just like the appendix, a diverticulum can become inflamed due to infection. If this occurs it causes local pain, can make a person feel ill, and can be dangerous because it may perforate or bleed. Inflammation of one or more diverticula is called diverticulitis.

A description of diverticular disease

In most people with diverticula the intestinal muscle is normal in appearance and thickness, but in some people it becomes thicker than normal and has an unusual structure under the microscope. The thickening of the muscle narrows the colon which becomes irregular in outline. The reason for this is not known but it is important to realise that it is not due to infection and may not be related to diet. The muscle abnormality can develop when very few diverticula are present and occasionally it occurs without any diverticula. The combination of abnormal muscle and diverticula is known as diverticular disease. This is confusing because diverticula and diverticular sound the same, hence the use of the word disease.

What are the symptoms of diverticular disease?

The muscle abnormality is the reason for the symptoms of pain in the lower and left side of the abdomen, bloating, irregular timing of the bowel opening with stools like pellets and also bowel actions containing small amounts of blood. Irritable bowel syndrome has similar symptoms as both of these conditions are partly related in that there is abnormal function of muscle.

The necessity of investigation

When conditions such as bleeding rectum or pain in the abdomen are investigated by endoscopy (sigmoidoscopy or colonoscopy) or x-ray barium enemas then diverticula are often discovered as a side effect. Elderly people who are well typically have diverticula so their importance as to the cause of the symptoms or not is important to establish. Evidence of inflammation on blood tests and tenderness of the diverticular area indicate the diagnosis is diverticular disease. The increased folds in the left, lower colon lining which can be present are the abnormal muscle finding in diverticular disease.

Explaining the situation

Reassurance that a more serious disorder is not present helps people not to worry about the symptoms. An explanation of the difference between symptoms due to infection and those due to abnormal contraction of the muscle, without inflammation, helps people understand why one treatment may be advised and not another.

When a hernia occurs a part of the bowel or abdominal fat, normally within the abdomen, protrudes out through a weakened part. An inguinal hernia is the commonest type and occurs in the groin. There is a small gap deep in the wall of muscle in the abdomen, just above the ligament in the groin, through which the veins and arteries course to reach the testicle. If the gap or the tissues around it stretch or weaken then part of the peritoneum (lining of the abdomen) can protrude through. This protrusion can occur, with fat or bowel bulging out, on vigorous activity, coughing or standing.

The bulging hernia area can cause discomfort, with the contents of the hernia sac usually going back into the abdomen on lying down, although sometimes they need to be pushed back gently. Sometimes a small hernia can cause aching without an obvious bulge and the hernia is then only found during examination by a doctor. If a hernia has been present for a long time then it can become very large, and in a man it can even fill the scrotum. When this happens, it may stay out most of the time, and prove very difficult to push back.

Inguinal hernias occur less frequently in females than males but femoral hernias, a different type, occur more frequently in females and can mostly be found on examination by a specialist. Femoral hernias are more likely to need to be repaired.

Hernias are usually troublesome only because they cause a bulge and aching whilst the most serious risk of a hernia is strangulation which means the bowel which becomes completely trapped and its blood supply may become cut off. The produces sudden severe pain and requires an urgent operation when the affected piece of bowel may need to be removed. Strangulation is not very common and many people have hernias for years without them ever becoming strangulated. Obstruction of the bowel can also occur it the bowel becomes trapped and this demands an operation even if the blood supply has not been cut off.

An operation is the only permanent cure for a hernia and can prevent the long term presence or increase in size of the hernia. Hernias can cause discomfort and strangulation can occur but is not common. An operation is not mandatory if the hernia is not causing any trouble and patients should discuss this with their surgeons. A symptomatic hernia can be held in place by a truss which needs to be put on before the patient gets up and makes the hernia bulge. A symptomatic hernia is mostly much better treated by an operation. Having medical problems or being older should not stop hernia repair due to the safe use of local and general anaesthetics.

A groin incision about 12 centimetres in length is used for the repair of a hernia, with an opening of a layer of muscle and then the careful separation of the bulging hernia sac from the veins, arteries and tube to the testicle. The protruding fat or bowel from the abdomen is compressed back in and the sac is then stitched back into the abdominal cavity or tied off at its narrow neck area.

The weakened area is then repaired and strengthened and the hole for the veins and arteries to the testicle is recreated back to its usual size. The hernia will be likely to return if it is not repaired, with surgeons typically using a plastic mesh which they stitch over the herniated area. Stitches can also be used without employing the mesh and this is more likely in femoral hernias. Good long term results have been shown with both techniques and the typical chance of hernia reoccurrence is 2%.

Some surgeons do the operation laparoscopically, under general anaesthetic. The telescope is inserted just below the tummy button and gas is introduced through the telescope to open up the space between the muscles in the lower part of the abdomen and groin. Two tiny 5mm incisions are made in the lower abdomen for further instruments to be inserted which are used to place a sheet of plastic mesh to repair the hernia.

When you suffer from just about any kind of pain, your casual activities are disrupted because you can’t perform these with any type of comfort and your focus is most of the time is on the pain that you are suffering from. If someone is hurting from arthritis pain, tendonitis pain, a headache, back pain or any type of pain, they will want to find relief as fast as they possibly can so that they can once again get back to their regular activities. Many times, it is not until you have a pain of some sort that you realize how fortunate you are everyday just to be pain free and able to do easy activities, as some pains can completely curtail you from moving.

Do Pain Relief Creams Work?

The response to this is yes and no, but will depend on the type of pain that you are suffering from, but for the most part they are going to provide quick and efficient pain relief. There are many types of pain relief creams directed to the specific needs you have and some of the most common pains that we face are: headaches, back and muscle aches and arthritis.

Pain relief creams work on initial stages mostly when your pain is not chronic. The greatest part about cream pain relievers are that they target the region of the pain when compared to drugs that have to be distributed into your whole system, but the cream pain reliever must be rubbed into the skin completely to be totally effective and work the fastest.

The Diverse Types of Pain Relief Creams

Some of the most sought after pain relief creams are the natural types, which are strong enough to provide you relief and does not have any side effects. Most pain relief creams don’t incorporate antibiotics and thus can be purchased over the counter without a prescription but if you are presently having a serious health problem it is wise to run it by your doctor for approval.

For the most part there are not any side effects when using pain reliever creams, but you can possibly acquire a rash if you have sensitive skin, but the rash should disappear without any type of medication, but if it does want to persist make sure that you call your doctor. Try not to apply more pain relief cream then indicated on the tube of the cream as some are strong enough to produce a light burn of the top layer of the skin where applied; using more cream will not get rid of the pain faster but can create more damage.

Some Other Tips

A lot of pain relieving creams have a very potent odor and can leave marks on the garments or bed sheets, to avert both look for odorless, non-oily creams to relieve your pains and aches without the mess.

Our ligaments, tendons, discs and skin are made up of forms of collagen, one of the most important structural proteins in our bodies. This gives our tissues the ability to heal, its elasticity, its integrity and its strength, allowing us to have strong and healthy joints and skin which will put up with the stresses life puts upon them. Collagen is also responsible for the strength and integrity of our arteries and many other bodily structures. Human populations show great variation in collagen function from those who are very stiff jointed to those who are very mobile jointed or “double jointed”.

Ehlers-Danloss syndrome is caused by an abnormality in the way collagen is produced and acted upon in the body, causing an inheritable deficiency in the strength of the substance. 10 forms of EDS are known to exist, with much overlap, and EDS Three is considered the same as benign joint hypermobility syndrome, called benign because the serious changes such as in the arteries are not present in this form. Very hypermobile joints are the most obvious sign of this syndrome, with a smooth, flexible skin which tends to heal slowly and scar poorly in terms of wide and thin scars.

Patients with joint hypermobility syndrome show various symptoms and signs: joint hyper-mobility; less skin strength; reduced healing of wounds; easy bruising; skin flexibility and likelihood to dislocate easily. Sufferers from this syndrome may develop a chronic pain syndrome with constant and persistent joint pain, with incorrect muscle balances leading to joint stability problems and poor muscle balance. Functionally hypermobile patients can be very limited in normal activities or suffer pain when undertaking them and are unable to join in with vigorous activities or contact sports.

Self management in hypermobility syndrome is the main aim of intervention, with patient education taking a strong role to equip the patient to manage their lifelong condition. Due to the abnormally large ranges of joint movement they are vulnerable to ligament or joint strain if they are held posturally at end range or moved with momentum. Hypermobile patients should practice joint protection like arthritic patients, avoiding party pieces like showing off with extreme movements or joint dislocations. Yoga or high momentum activities such as contact sports are particularly unsuitable for these patients.

The stresses and strains of daily life and recreational activities tend to result in more acute injuries and pain complaints in hypermobile patients which are managed by physiotherapy to the joints and muscles. Even in normal circumstances the shoulder is very mobile yet unstable but in hypermobile patients the lax connective tissue makes the joint very unstable and difficult to control. The shoulder and surrounding muscle must keep the large ball of the arm bone aligned with the small socket during large movements and this is difficult with hypermobility, leading to abnormal muscle patterns and pain. It is common to have pain due to this and to repeated dislocations.

Spinal pain, in the neck, low back or thoracic regions, is a common symptom which hypermobile patients complain of, and physiotherapists interpret this as a lack of stabilising muscle control and muscle balance. Physios do not manipulate these patients but mobilizations, core stability work, strengthening weak muscle groups and general exercise are typical approaches. Increasing the usually low muscle tone by gentle weight training or using resistive bands can help joint control in the mid positions and avoid stresses at end ranges. Hyperextension of the knee is a typical problem, leading to joint pain on weight bearing and later to osteoarthritis. Hamstring work to strengthen the muscle opposing the abnormal movement is useful, with patients typically working on the muscle balance of several body areas.

All postures and activities are a challenge to a patient with hypermobility as unsuitable stresses are very easy to apply, causing pain. The patterns of muscle activity are abnormal when the joints are under load, pushing them into end range positions where the ligaments and capsules suffer from strains. Physiotherapy retraining of poor muscle balance can be helpful but patients need to be constantly vigilant and work at their weaknesses persistently. The most important factor overall is patient education as the condition is a long term one and all physical activities challenge the joints.

The gleno-humeral joint, known in lay terms as the shoulder, is a vital part of the links in the upper limb and responsible for our ability to place our hands where we can see them to perform activities. Because flexibility is a prime requirement the shoulder is a less stable joint with moderate muscle power and a large range of motion. It is described as a “soft tissue joint”, implying that the joint’s functional ability is dependent on its soft and not its hard components. Physiotherapists are closely involved in treating and rehabilitating the shoulder, dealing with the muscles, ligaments and tendons.

The gleno-humeral joint is made up of the ball of the humerus and the socket of the shoulder blade which is called the glenoid surface. The top of the arm bone, the humeral head, is large and carries many of the tendon insertions for the stability and movement of the shoulder. The socket or glenoid is a relatively small and shallow socket for the large ball but is deepened slightly by a fibrocartilage rim called the glenoid labrum. Above the shoulder is the acromio-clavicular joint, a joint between the outer end of the collar bone and part of the shoulder blade, a stabilizing strut for arm movement.

A great many muscles act on the shoulder joint and on the other joints in the shoulder girdle, the acromioclavicular, sternoclavicular and scapulothoracic joints. The glenohumeral and scapulothoracic joints are acted upon by the major stabilisers and movers in the area, varying from power muscles which allow forceful work to stability muscles such as serratus anterior and the rotator cuff to smaller movement muscles such as deltoid. The muscles must keep the relationship between the shoulder blade and the thorax and ribcage steady and under control for the glenohumeral joint to also enjoy stability and precise movement.

The shoulder muscle tendons become flatter and thinner as they approach and then insert themselves onto the head of the humerus. By this way the rotator cuff, a group of four muscles including the supraspinatus, infraspinatus, teres minor and subscapularis, is able to exert its forces on the humeral head. The tendons coalesce as they surround and insert onto the ball of the humerus, forming a cuff around the ball, centering the ball on the socket to counter the tendency to slide upwards under muscle activity. Keeping the ball centred on the socket means the larger and more powerful muscles can perform functional shoulder and arm movements.

As a person ages, the rotator cuff develops degenerative changes in its tendinous structures, causing small tears in the tendons which can enlarge until there is no continuity between the muscles and their attachments. This leads to loss of normal shoulder movement and can be very painful but is not always so and “Grey hair equals cuff tear” is a common saying. Physios work at rotator cuff strengthening, whilst in massive tears the main shoulder muscles can be progressively strengthened to improve function. Surgery is possible for massive, moderate and small rotator cuff tears and physiotherapists manage the post-operative protocols.

The shoulder joint is not typically affected by OA (osteoarthritis) but when it is physiotherapists treat arthritic shoulders by joint mobilisations, muscle strengthening and ranges of motion. Once physio has nothing else to offer, total shoulder replacement is one of the further options, with various surgical techniques involving replacing the humeral ball and the scapular socket either anatomically or in reverse. The shoulder is often called a “soft-tissue joint” as the soft tissues, their strength and balance, are vital to the function of the joint. Post-operative physio management is essential as the correct protocol must be closely followed to ensure success.

Many other shoulder conditions are managed by physiotherapists, such as hyper-mobility, dislocations and fractures, impingement and tendinitis. Physios manage shoulder hyper-mobility by patient education and stability training and abnormal muscle activity by teaching correct patterns by repetition and biofeedback. Physiotherapy for impingement involves rotator cuff strengthening, sub-acromial injection or surgical management by acromioplasty and tendinitis by local treatment and strengthening. Dislocations and fractures are managed according to the type and severity of injury and according to the trauma surgical and physiotherapy protocols.

The largest and the strongest tendon in the body is the Achilles tendon in the distal posterior calf. Typical patients with Achilles tendon rupture are men in good health from 30-50 years old and who have not suffered major injuries or any kind of difficulty with the leg before. Rupture occurs typically in people who have not been recently active and who may indulge in infrequent physical activity such as playing weekend sport, players known as “weekend warriors”.

The two large calf muscles, the gastrocnemius and the soleus, each have a tendon and these converge and form the Achilles tendon about 15 centimetres above the calcaneum. Tendons transmit forces from muscles to bones and to do this they have high resilience and sufficient stiffness, good tensile strength and allow 4 percent stretch before damage. Damage and rupture to the fibres can occur when the stretch reaches 8 percent. Most of the tendon rupture and degeneration occurs where the blood supply is poorest, about 2-6 centimetres up from the heel bone.

Achilles tendon tears occur mostly in the left leg where the poor blood supply is, perhaps because most people are right handed and push off more with their left leg. Common injuries are on sudden foot push off, an unexpected forcing up of the ankle and an upward force on the ankle when pushed down. Direct trauma and general degeneration of the tendon without trauma can also occur. People at risk include those exerting themselves when they are unfit, relatively older people, steroid users and those who exert themselves in extreme ways.

Achilles tendon forces in running can be very high and have been measured at six to eight times bodyweight. The patient typically reports a sudden snap or blow to the rear of the lower calf, a sudden strong pain, an ability to walk but not to run or climb stairs. On examination there may be a swollen or bruised calf, a palpable gap in the tendon and an inability to stand on tiptoe. A history of treatment with steroids, previous tendon rupture or an unusually high activity level (e.g. weekend warrior) can also be important findings.

Doctors choose conservative or surgical management, operation having a higher risk of complications and conservative treatment a higher risk of re-rupture. Non-operative treatment is suitable for sedentary people, diabetics, older people and those with medical problems or poor skin integrity. Impaired blood supply, diabetes and other illnesses make wound breakdown, tendon separation and infections more likely. A calf or thigh length plaster may be used with the ankle flexed down, moving it up regularly over six to ten weeks. The patient is allowed to weight bear and given an orthotic as the tendon heals.

Open or percutaneous surgery can be used and after the operation the leg is plastered with the ankle in plantar flexion or put into a brace. The ankle angle is adjusted upwards regularly week by week as healing goes forward until after 4 to 6 weeks the brace can be removed. Surgical repair is more successful due to lower rates of repeated rupture, quicker return to activity, greater strength and better endurance when compared to non-operative treatment. Research indicates that immobilizing the tendon for shorter periods is more successful.

The physiotherapy rehabilitation starts with ankle range of movement exercises without body weight loading, encouraging a good walking pattern and a heel raise to reduce the upward force on the tendon in gait. Static cycling and swimming are good starting activities, moving onto weight bearing exercises, muscle strengthening and onto more vigorous activities such as jogging, jumping and balance practice. Normal activity may be resumed by four months from surgery but this varies.

Achilles tendon rupture usually turns out with good or excellent results with most athletes getting back to their chosen sports. Surgical management has a re-rupture rate of 0-5 percent and conservative treatment up to 40 percent, so patient education by the physio in training and stretching performance and the best choice of footwear is important for the long term.