A mobile thoracic spine allows you turn your back in many directions, enabling you to do everyday tasks with ease. Today’s sedentary lifestyle often contributes to reduced spinal mobility. Basically ”motion is lotion” and if you are inactive and also prone to poor posture, your thoracic spine can seize up. If it goes on long enough, say into old age portions of the spine may fuse and not move at all. A lack of thoracic spine mobility means that the lumbar spine, pelvis, shoulders and surrounding muscles have to compensate. Long term, these over-compensations can lead to overuse conditions and injuries, the lower back being particularly suceptable. This is because the lumbar spine is meant to keep us stable and is not very mobile, so when these joints are forced to overcompensate for the lack of movement in the thoracic area, it can place alot of pressure on the discs of the lower back. Possible consequences include inflammation, degeneration, herniation of the discs, generalized low back pain, compression fractures, muscles spasms, and spinal nerve injuries. Similar pressures and injuries can occur in the neck and shoulders. For example, if your thoracic spine isn’t mobile, anytime you have to do a movement overhead, your shoulders make up for that lack of mobility. If you have shoulder impingement or chronic shoulder and neck problems lack of mobility in the thoracic spine will make every thing worse.
Improving Thoracic Spine Mobility
Yoga, pre- and post-workout stretching, and mobility exercises are the best way of maintaining and improving thoracic spine mobility. These need to be done regularly and consistently, especially as you get older. Your physiotherapist will be able to guide you on the correct exercises and help correct your form and technique until you get used to them and can do them yourself. Here are a few exercises to get you started.
Chondromalacia patella, also known as ”Runners Knee” is one of the most common causes of knee pain in runners. The condition results from irritation of the cartilage on the under-surface of the kneecap. This cartilage is smooth and the kneecap normally glides effortlessly across it during bending of the knee joint. In some individuals however the kneecap does not track so smoothly due to poor alignment and the cartilage surface becomes irritated, resulting in inflammation and knee pain. In more severe cases there can be breakdown of the cartilage. Chondromalacia patella can affect athletes of any age but tends to be more common in women, most likely due to anatomical differences between the sexes ie. wider hips in females which results in a greater angulation between hip and knee, thus resulting in increased lateral forces on the patella.
Chondromalacia Patella – Causes
There are several causes both structural and dynamic which are linked to the condition. These include excessive foot pronation(feet turn out when running etc.), tight IT band, tight vastus lateralis(basically outer lower quad), weak or slow firing vastus medialis (basically lower inner quad), increased Q angle (simply put the angle between the outer hip and centre of the knee), a lateral femoral condyle that is not sufficiently prominent anteriorly (simply put the knee joint does not fit together properly),and a small or high riding patella(knee cap).(McConnell, 2002)
Chondromalacia Patella – Symptoms
The most common symptom is a dull, aching pain in the front of the knee, behind the kneecap. This pain is often worse when you go up or down stairs. It also can flare up after you have been sitting in one position for a long time. For example, your knee may be painful and stiff when you stand up after watching a movie or after a long trip in a car or plane. In some cases, the painful knee also can appear puffy or swollen. Chondromalacia can sometimes cause a creaky sound or grinding sensation known as ”crepitus” when you move your knee.
Chondromalacia Patella – Physio Treatment
Suitable treatment may involve 1. Soft tissue work to loosen tightened structures such as vastus lateralis muscle, IT band, lateral retinaculum etc., 2.Strengthening of weak structures such as vastus medialis, glutes , hip abductors etc., 3. Correction of overpronation using orthotics, 4. Non steroidal anti-inflammatories such as ibuprofen to reduce pain and inflammation, 5. Rest with gradual return to exercise, 6. Taping to correct tracking can be a short term solution.(Hertling and Kessler, 2006) while you strengthen the vastus medialis muscle. Also there are supports you can purchase to help correct patella tracking while exercising. These are a good short term solution while you correct the problems referred to above. Here is a good example.
If nonsurgical treatments fail, or if you have severe symptoms, your doctor may recommend arthroscopy to check the cartilage inside your knee. If the cartilage is softened or shredded, damaged layers can be removed during the surgery, leaving healthy cartilage in place .
Hertling, D., Kessler, R.M. ”Management of Common Musculoskeletal Disorders : Physical Therapy Principles and Methods.” Lippincott, Philidelphia 524-533, 2006.
Mc Connell, J. ”The physical therapist’s approach to patellofemoral disorders.” Clinical Sports Medicine 21:363-387, 2002.
For more information on chondromalacia patella see this video.
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Plantar plate injuries are easily missed, probably because a lot of people don’t know what the plantar plate is. Quite they are diagnosed under the general term metatarsalgia. The plantar plate is a deep fibrocartilaginous structure that originates from the metatarsal head and attaches to the proximal phalanx through the joint capsule within the forefoot. Its role is to help stabilize the metatarsophalangeal joints (MTPJ), along with a couple of other structures. The plantar plate also acts as an attachment site for the plantar fascia, so if you load the foot, the medial arch lengthens, the plantar fascia tightens, this engages the plantar plate to plantarflex the proximal phalanx until the toe reaches the ground. This is a simplification of a complex process and is commonly known as the The ‘reversed’ windlass mechanism (with weight-bearing the longitudinal arch flattens, the foot lengthens, the plantar fascia tightens, the proximal phalanx becomes plantarflexed and the mechanism comes to a stop when the proximal phalanx presses against the ground).
What causes a plantar plate injury and how common are they?
There are many contributing factors. The first is any activity that exposes the MTPJ to repetitive and excessive dorsiflexion, so think about jumping and running especially in forefoot runners. There are a few biomechanical conditions that increase the load through the plantar plate such as hallux valgus (bunions). As the function through the 1st MTPJ(big toe) is reduced, then we get what is known as low gear propulsion and increased loading through lesser MTPJs, typically the 2nd, 1st, then 3rd and so on. Another condition like having say an irregular metatarsal length, for example, if you have a long 3rd metatarsal, can expose the plantar plate to increased load, as can external factors like high heels. Basically anything that will result in excessive dorsiflexion or ground reaction forces at the MTPJs may increase plantar plate loading.
How does a plantar plate injury present?..
The patient will complain of pain on the dorsal and plantar aspects of the MTPJ, usually described as an ache or bruising.
Mild oedema may be present along with an episode of trauma, however, trauma is not essential as plantar plate injuries are typically a chronic overuse injury
Reduced plantarflexion strength – The ‘Digital Purchase’ test
A quick way to do this, put a piece of paper under the apex of the affected toe and ask the patient to try and stop you pulling the paper away, in a plantar plate injury you will notice the paper is pulled away much more easily.
Pain, oedema and positive Digital Lachmans (Anterior Draw) / Vertical Stress.
Floating toe, if late-stage hammertoe, or Churchill sign may be present.
Diagnosis of plantar plate injuries
Digital Lachmans / Vertical Stress Test (Fig 1)
Same style of test to assess ACL tears, helps to assess the integrity of the plantar plate, it is quick, easy and a simple test to perform. Stabilise the head of the metatarsal with one hand, using the other hand stabilise the base of the proximal phalanx, apply a vertical force, we are looking for pain and any translocation, it is important to remember this is different from dorsiflexion of the digit.
There are 2 scoring systems one by Thompson and Hamilton and the other Yu and Judge
Thompson and Hamilton
Stage 0, there is no dorsal translocation present of the proximal phalanx.
Stage 1 the base of the phalanx, will not dislocate, however, may sublux
Stage 2 the base of the phalanx can be dislocated.
Stage 3 the phalanx base is in a fixed dislocated position
Yu and Judge
Stage 1 mild odema on the plantar MTPJ with dorsal odema often present as well. Tenderness is present on palpation, however no anatomical malalignment.
Stage 2 moderate odema is present with a noticeable deviation.
Stage 3 odema present around the entire MTPJ with deviation and possible dislocation/subluxation, the odema will reduce however the deformities will remain.
I think the best way to describe the 2 different methods of testing, would be that the Thompson and Hamilton test best describes the integrity of the plantar plate at any given time, whereas the Yu and Judge test describes different stages based on clinical findings on the time of examination.
MRIs, X-rays and Ultrasound
There is still some debate as to whether an MRI scan or ultrasound scan is best for detecting plantar plate injuries. As we know ultrasound is cheaper, however, it is user-dependent, whereas MRI scan is more expensive but we can also get an overall picture of the structures within that area as well. X-ray in weight-bearing (lateral or oblique views) will show subluxation dorsally of the proximal phalanx on the metatarsal head, an anterior-posterior view will show a transverse deformity as well. An x-ray will also rule out other bony pathologies.12
Treatment of plantar plate injuries
The aim of treatments, like most musculoskeletal pathologies, is about managing the load. Essentially we want to try and reduce the ground reaction forces under the affected metatarsal head and reduce the plantarflexion moment of the metatarsal and the dorsiflexion of the phalanx.
Treatment protocols include
No barefoot walking/activity modification
Footwear advice / Air cast boot – we want to look at using a stiff-soled shoe, or reducing the heel height of a shoe, so footwear like high heels and the flexible minimalist type shoes tend to aggravate a plantar plate injury, the same goes for open-toe shoes and flip-flops, as you must claw your toes to keep these on which again increases the ground reaction force underneath the metatarsal.
Stretching / Strengthening – thinking about the mechanics of the foot, if there is tightness within the calf muscles, in turn, could result in early and increased loading through the forefoot, and if you are unable to get adequate dorsiflexion due to calf tightness, then the foot may pronate to compensate for this, which in turn could increase the loading through the lesser MTPJ’s. It is important also to work on strengthening the muscles within the foot.
Strapping can be very helpful in reducing pain, using a rigid zinc oxide tape and pulling the toe into a plantarflexed position to help offload a plantar plate (Fig 2).
Orthotics can be a useful way to help offload the affected plantar plate. One of the best ways to treat Plantar Plate Injures with or without surgery is using an orthotic device that places the pressure into the archway and off of the ball of the foot. If manufactured and molded correctly, they can keep the tension off the injury and pressure when standing and walking. Combining the orthoses with taping and footwear advice can be quite an effective way of offloading the affected plantar plate, whilst the patient reduces sporting activities.
Steroid injections can be tried , however repeated intra-articular injections has been shown to result in dislocation of the MTPJ. It has also been suggested that injections into a ligament resulted in destruction of fibrocytes and reduction in tensile strength for up to 1 year which in turn may result in further damage a possible rupture.
A recent case study showing a patient with a plantar plate tear was managed using conservative measures, consisting of taping, activity modification and the use of a Darco boot over a 6 month period, and progressing to stiffed shoe and orthoses and stopped taping. At the 1 year mark, the patient was pain-free with no toe deformity, and on MRI the plantar plate has healed.
So what’s my treatment plan?
No barefoot walking for 6 weeks (minimum)
To wear stiff-soled shoes
Strapping of digit changing every 72 hours
Orthoses as described as above, plus any other modifications required
Stretching and Strength work – Distal and proximal
If conservative measures fail, then it may require referral to a surgeon.
Physiotherapist in Tralee. Ring to discuss your condition, to get a second opinion or to make an appointment. Click here for website.
Herniated Disc vs Bulging Disc
Your spine is made up of lots of bones called vertebrae and discs stacked on top of one another, forming the spinal canal. The nerves of the spinal cord run down the length of the spinal canal. The discs in act like shock absorbers between the vertebrae. These discs are made of two components: a softer center (called nucleus pulposus) surrounded by a tough elastic-like band (called annulus fibrosus). A bulging disc is like a squashed jam doughnut before the jam bursts out. The disc sags and looks like it is bulging outward. With a herniated disc, the outer covering of the disc has a hole or tear. This causes the nucleus pulposus (jelly-like center of the disc) to leak into the spinal canal. It is like the jam leaking out from the inside of a squashed jam doughnut.
Bulging discs are usually caused by age-related degeneration. There is usually a progressive, gradual onset of symptoms. Bulging discs and herniated discs can occur anywhere along the spine. Pain from a herniated disc usually comes on abruptly often affecting one individual nerve root. Herniated discs are often caused by an acute injury. In some cases, you may know the cause of the injury, such as twisting incorrectly.
Herniated and bulging discs are the most common causes of lower back pain, as well as leg pain or ”sciatica.” Between 60% and 80% of people will experience low back pain at some point their lives. Although a herniated disk can be very painful, most people feel much better with just a few weeks or months of nonsurgical treatment, such as using muscle relaxants and anti-inflammatory medications, along with physiotherapy. Long term management of these conditions needs to including properly prescribed strengthening and flexibility exercises in order to avoid surgery. Surgery is the final option.
For more on herniated and bulging discs, see video.
Physio in Tralee. Phone 0867700191 to discuss your condition or make an appointment.
Peroneal tendonitis occurs when the peroneal tendons become inflamed. This happens when there is an increased load on and/or overuse of the tendons. This causes the tendons to thicken over time. If the injury becomes chronic, the tendinitis can progress to tendinosis. This is more serious and takes longer to treat.
Peroneal tendonitis is particularly common in athletes especially runners , more so if their feet roll outwards during gait(over supination).
There are two peroneal tendons in each leg peroneus brevis and peroneus longus. They run side by side down the outside of the lower leg bone (fibula) and behind the bony lump on the outside of the ankle, the lateral malleolus. One peroneal tendon attaches to the outside of the foot at the base of the little toe (fifth metatarsal). The other tendon goes underneath the foot and attaches to the inside of the arch.The peroneal tendons provide stability to the ankle when it is bearing weight and protects it from sprains. They also help turn the foot out and stabilize the arch when walking.
Causes of Peroneal tendonitis
People who take part in a sport that involves repetitive ankle motion are most prone to peroneal tendonitis Factors that can contribute to peroneal tendonitis include:
a sudden increase in training, particularly weight-bearing activities, such as walking, running, and jumping
improper training techniques
inadequate or un-supportive footwear
There are also some other issues that can increase a person’s risk of developing peroneal tendonitis:
higher foot arches
lower limb muscles and joints not working well together
imbalanced muscles in the lower limbs
If someone fails to complete a rehabilitation program following an ankle injury, such as a sprain, they are also more likely to develop peroneal tendonitis. Over time, the damaged peroneal tendons will thicken as scar tissue tries to repair the damaged area. This makes the tendons weaker and more prone to tearing. Treatment can include orthotics to support the foot and take pressure off the tendon, wearing well laced up supportive footwear, very specific rehab program. Also instrument assisted soft tissue work seems to be beneficial, stripping out the tendon and promoting healing.
Meniscus injuries are a relatively common knee injury. Cartilage within the knee joint provides cushioning between the bones at this joint. This protects them from the stresses of walking, jumping, running etc. There is articular cartilage which is the smooth, white tissue that covers the ends of bones(Femur, tibia) where they come together to form the knee joint. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction. Articular cartilage can be damaged by injury or normal wear and tear.
Within the knee you also have fibrocartilage in the form of the medial and lateral meniscii. These are two thick wedge-shaped pads of cartilage attached to top of the tibia (tibial plateau) and under the femur bone. They allow the femur to glide when the knee joint moves. Each meniscus is curved in a C-shape, with the front part of the cartilage called the anterior horn and the back part called the posterior horn. Meniscal tears are usually described by where they are located anatomically in the C shape and by their appearance (for example, “bucket handle” tear, longitudinal, parrot beak, and transverse).
Because the blood supply is different to each part of the meniscus. Knowing where the tear is located may help decide how easily an injury might heal (with or without surgery). The better the blood supply, the better the potential for recovery. The outside rim of cartilage has better blood supply than the central part of the “C.” Blood supply to knee cartilage also decreases with age, with up to 20% of normal blood supply lost by age 40.
What causes a meniscus to tear?
A forceful twist or sudden stop can cause the end of the femur to grind into the top of the tibia, pinching and potentially tearing the cartilage of the meniscus. These meniscus injuries can also occur with deep squatting or kneeling, especially when lifting a heavy weight. Meniscus tear injuries often occur during athletic activities, especially in contact sports like football and hockey. Motions that require pivoting and sudden stops, in sports like tennis, basketball, and golf, can also cause meniscus damage.
Meniscus injuries – Increasing risk with age
The risk of developing a torn meniscus increases with age. This is because cartilage begins to gradually wear out, losing its blood supply and its resilience. Being overweight also puts more stress on the meniscii. This means that routine daily activities like walking and climbing stairs increase the potential for wear, degeneration, and tearing. It is estimated that six out of 10 patients older than 65 years have a degenerative meniscus tear. Many of these tears may never cause problems.
Some of the fibers of the cartilage are interconnected with those of the ligaments that surround the knee. Thus, meniscus injuries may also be associated with tears of the collateral and cruciate ligaments, depending upon the mechanism of injury.
Symptoms of meniscus injuries can include some or all of the following:
Pain with running or walking longer distances
Intermittent swelling of the knee joint: Many times, the knee with a torn meniscus feels “tight.”
Popping, especially when climbing up or down stairs
Giving way or buckling (the sensation that the knee is unstable and the feeling that the knee will give way): Less commonly, the knee actually will give way and cause the patient to fall.
Locking (a mechanical block where the knee cannot be fully extended or straightened): This occurs when a piece of torn meniscus folds on itself and blocks full range of motion of the knee joint. The knee gets “stuck,” usually flexed between 15 and 30 degrees and cannot bend or straighten from that position.
The diagnosis of a knee injury begins with a history of the injury etc. and physical examination. There have been many tests described to assess the internal structures of the knee. The McMurray test is one long used orthopedic test . The health-care professional flexes the knee and rotates the tibia while feeling along the joint. The test is positive for a potential tear if a click is felt or noticeable pain is felt while circumducting the knee in full flexion.
Physiotherapy in Tralee – referral for MRI
(MRI) is the test of choice to confirm the diagnosis of a torn meniscus. It also allows a radiographer to visualize the inner structures of the knee. These structure include; the cartilage and ligaments, the surface of the bones, and the muscles and tendons that surround the knee joint. Plain X-rays cannot be used to identify meniscal tears but may be helpful in looking for bony changes, including fractures, arthritis, and loose bony fragments within the joint. In older patients, X-rays may be taken of both knees while the patient is standing. This allows the joint spaces to be compared to assess the degree of cartilage wear. Cartilage takes up space within the joint and if the joint space is narrowed, it may be an indicator that there is less cartilage present, likely from degenerative disease.
Treatment of Meniscal Tears
Sometimes conservative measures such as physical therapy, NSAIDs and rest can be enough to settle the condition. When conservative measures are ineffective the next step may be surgery to repair or remove the damaged cartilage.
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Trigger-point dry needling is a procedure where a fine acupuncture needle is inserted into the skin and muscle. It is aimed at myofascial trigger points, which are points of exquisite pain in skeletal muscle, that are associated with a hypersensitive palpable nodule or a taut band.
Active trigger points can spontaneously trigger local or referred pain. They cause muscle weakness, restricted range of movement and autonomic phenomena. Latent trigger points do not cause pain unless they are stimulated. They may alter muscle activation patterns and contribute to restricted range of movement . Therefore both active and latent trigger points cause allodynia(nerve pain) at the trigger point site and hyperalgesia away from the trigger point following applied pressure.
The formation of trigger points is caused by the creation of a taut band or knot within the muscle. This band is caused by excessive acetylcholine release from the motor endplate combined with inhibition of acetylcholine esterase and upregulation of nicotinic acetylcholine receptors. Motor end plates, also called neuromuscular junctions, are specialised chemical synapses formed at the sites where the terminal branches of the axon of a motor neuron contact a target muscle cell. Motor neurons are nerve cells that send electrical output signals to the muscles.
Initially the taut bands are produced as a normal protective, physiological measure in the presence of actual or potential muscle damage. They are thought to occur in response to unaccustomed eccentric or concentric loading, sustained postures and repetitive low load stress. However when sustained they contribute to sustained pain. The pain caused by trigger points is due to hypoxia and decreased blood flow within the trigger point. This leads to a decreased pH which activates the muscle nociceptors to restore homeostasis. This causes peripheral sensitization. Trigger points are also involved in central sensitization. The mechanism remains unclear but trigger points maintain nocioceptive input into the dorsal horn and therefore contribute to central sensitization.
Stimulation of a local twitch response (LTR)
Dry-needling of these myofascial trigger points via mechanical stimulation causes an analgesic effect. This mechanical stimulation causes a local twitch response (LTR). A LTR is an involuntary spinal cord reflex contraction of the muscle fibers in a taut band. Triggering an LTR has been shown to reduce the concentration of nociceptive substances in the chemical environment near myofascial trigger points.
The needle may also cause a small focal lesion which triggers satellite cell migration to the area which then repair or replace damaged myofibers. This occurs 7-10 days after dry needling. It is unclear whether continued dry needling within this period may disrupt this process.
Dry needling may also cause a localized stretch to the cytoskeletal structures. This stretch may allow sarcomeres to resume their resting length. The mechanical pressure causes collagen fibers to intrinsically electrically polarize which also triggers tissue remodeling.
The effectiveness of this treatment depends greatly on the skill of the therapist to accurately palpate mysofascial trigger points.
Physiotherapists in Tralee specializing in hand-on deep tissue work, dry needling and osteopathic manipulations. Phone 0867700191 to discuss your condition or make an appointment.
What is Hallux Rigidus?
Big toe joint arthritis (otherwise known as Hallux Rigidus) is a form of degenerative arthritis. In this condition, surfaces of the joints in the big toe begin to wear away and extra bone can also develop in the form of bone spurs or osteophytes. This limits the movement of the joint. The big toe needs to bend significantly when stepping off. Consequently, arthritis in this joint can greatly affect walking, running etc.
Hallux Rigidus is a condition that tends to get worse over time. In it’s earlier stages, it may be referred to as Hallux Limitus, which is where there is limited movement of the big toe joint. With progression, Hallux Rigidus develops which can result in stiffness developing in the big toe joint and there may also be swelling.
To compensate for pain in the big toe joint, people with Hallux Rigidus tend to adjust their walking pattern which can also result in knee, hip or lower back pain. There is often difficulty finding shoes that fit properly shoes due to pain and/or inflammation in the joint. Early diagnosis can be made by physical examination and x-ray. Early treatment gives the best chance of avoiding surgery.
What causes Hallux Rigidus?
The big toe joint is designed to bear a considerable amount of stress during walking. However faulty biomechanics or structural abnormalities such as flat feet can stop the big toe from bending normally, and eventually lead to the development of osteoarthritis in the big toe joint. Other factors that can increase the risk of developing this condition include genetics (eg, having a certain foot type), injury to the big toe , other inflammatory diseases, and working in a job that places excessive stress on the big toe joint .
In cases of Hallux Rigidus, certain types of footwear and orthotics may be recommended to reduce pressure and motion on the big toe. Custom orthotics that conform very closely to the arch of the foot are most effective in improving big toe joint function. These orthotics may incorporate something like a 3mm kinetic wedge in combination with a built in forefoot posting to take the pressure off the big toe joint. Ice and anti-inflammatory medication can also be used to reduce inflammation and pain. If it does not respond to conservative treatment, surgery may be recommended as a last resort in more severe cases.
Posterior ankle impingement is a condition characterised by tissue damage at the back of
the ankle joint due to compression of these structures. This occurs when the foot and ankle
are pointed maximally away from the body (plantarflexion – figure 1. ). It may occur when
compressive forces are too repetitive and/or too forceful. This can occurs in the presence of
ankle swelling or bony anomalies, such as additional bone, a condition known as an “os
trigonum”. Posterior ankle impingement is most commonly found in gymnasts, ballet
dancers, and footballers, because they regularly maximally plantarflex their ankles during
their activities. The condition can also occur due to inadequate rehabilitation of an acute
ankle injury (ie. ankle sprain).
Mechanism of Injury
Posterior ankle impingement may develop due to an acute traumatic plantar hyperflexion
event, such as an ankle sprain. It may also occur as a result of repetitive low-grade trauma
associated with plantar hyperflexion, say like in case of a female ballet dancer. It is
important to differentiate between these two, because the latter, that is posterior
impingement from overuse, has a better prognosis.
The anatomy of the posterior ankle is a key factor in the occurrence of posterior
impingement syndrome . The more common causes of the condition are osseous in nature,
such as the os trigonum, an elongated posterolateral tubercle of the talus (known as
Stieda’s process), a downward sloping posterior lip of the tibia, an osteophyte from the
posterior distal tibia , or a prominent posterior process of the calcaneus. However, posterior
impingement can also be soft tissue related, as with a thickened posterior joint capsule ,
post-traumatic scar tissue, post-traumatic calcifications of the posterior joint capsule, or
loose bodies in the posterior part of the ankle joint. Symptoms for all of these conditions
relate to physical impingement of osseous or soft tissue structures, resulting in painful
limitation of the full range of ankle movement.
The most common cause ''os trigonum'' is an extra (accessory) bone that sometimes
develops behind the ankle bone (talus). The mineralized os trigonum appears between the
ages of 7 and 13 years and usually fuses with the talus within 1 year, forming the trigonal
(Stieda) process. It may remain as a separate ossicle in 7-14% of patients, and is often
bilateral(in both ankles). An os trigonum can be a focus of osseous abutment against other
structures. Pain can also be caused by disruption of the cartilaginous synchondrosis
between the os trigonum and the lateral talar tubercle as a result of repetitive microtrauma
and chronic inflammation.
In the case of soft tissue impingement it usually results from scarring and fibrosis associated
with synovial, capsular, or ligamentous injury ie. bad ankle sprain. It is thought that this
type of manifestation usually usually occurs when a significant soft-tissue component
forms. The soft-tissue component can consist of synovial thickening throughout the
posterior capsule or be more focal, involving the posterior intermalleolar or talofibular ligament. The flexor hallucis longus tendon runs in the groove between the lateral and
medial processes of the talus and can also be injured in posterior impingement, resulting in
Signs and symptoms
Patients who have posterior impingement complain of chronic deep posterior ankle pain
worsened by forced plantar flexion or push-off forces as occur during activities such as
ballet dancing, jumping, or running downhill. In some patients, forced dorsiflexion(opposite
to plantarflexion) is also painful. Physical examination reveals pain on palpation over the posterolateral talar process, which is located along the posterolateral aspect of the ankle between the Achilles and peroneal
tendons . Passive forced plantar flexion results in pain and often a grinding
sensation as the posterolateral talar process is entrapped between the posterior tibia and
Diagnosis of posterior ankle impingement
A thorough examination by an experienced practitioner may be all that is necessary to
diagnose posterior ankle impingement. Further investigations such as an X-ray, MRI, CT scan
or Ultrasound may help confirm diagnosis.
Suboccipital muscles (see image) are a group of four muscles located on each side of the upper cervical spines, just below the base of the skull. The muscles connect the base of the skull with the top two vertebrae (C1 and C2) of the neck.
Poor posture in general especially with the increased use of portable electronic devices, which include mobile phones, laptops, and tablets has increased the prevalence of neck pain in both children and adults. Increased screen time on these devices is not only correlated with depression, sleep interruption, and poor food choices, but also rising rates of neck pain, especially in adolescents and young adults. This form of neck pain, including dysfunction of C1 and altered mechanics of the cervical spine due to poor posture, can also lead to headaches. Reading in bed is also a big offender. Any position where your head and neck are positioned forward and in a stationary position for long periods on time increases the likelihood of postural related spinal issues(ie. kyphosis, discogenic disorders etc.), neck pain and headaches.
These suboccipital muscles play an important role in controlling movements of your head and neck, providing sensory input and are also linked closely to vestibular and balance functions. However, when the suboccipital muscles become tightened, the following symptoms may occur. These could include:
Headaches with a band of pain on the side of the head that extends from the back of the head to the eye as a result of active trigger points. This type of pain feels deep in the head, and often it is difficult to describe.
Messages sent to the brain may be altered, which is also why sometimes headache sufferers may also experience sensory symptoms, including dizziness and visual disturbances.
Treatment includes deep tissue work, trigger point release, manipulation, mobilisation, postural education and a rehabilitation program.