What is Torticollis – Congenital and Acquired

Common conditions, Health, Injury, Pain

MAIN WRY NECK

What is Torticollis?

Torticollis is derived from the Latin word tortus, meaning “twisted” and collum, meaning “neck”.  It is an abnormality, where the muscles in the neck that control the position of the head are affected causing the head to tilt and/or rotate to one side or be pulled forward or backward. This condition is also known as “Wry neck” or “Cervical dystonia”.

What happens in torticollis?

Acute injury to the soft tissue structures of the neck is the most common presentation that causes inflammation, spasm and shortening of the muscles of the neck. Characteristic head tilt with the ear moved toward the shoulder happens from an increased tone in the neck muscles. 

Most commonly, the trauma is to one of the neck muscles called sternocleidomastoid (SCM). This muscle is present in front of the neck on each side and runs diagonally from the collar (clavicle) and breastbone to the mastoid process and the base of the skull bone as shown in Fig 1.

sternocleidomastoid FRONT VIEW

In torticollis, there is shortening or excessive contraction of the SCM on one side of the neck. The head is typically tilted sideways towards the affected SCM and rotated with the chin facing to the opposite side as shown in Fig 2. 

CT

Pathophysiology of torticollis

As shown in Fig 2, Torticollis can be of two types.

  • Congenital
  • Acquired

Congenital Torticollis

“Congenital” means a physical abnormality present from birth. Congenital torticollis is an abnormal positioning of the neck caused due to the damage of the nerves or the blood supply of the neck. This occurs due to various reasons such as, 

  • Intrauterine (inside uterus) malposition of the baby 
  • Trauma while undergoing breech or difficult forceps delivery, fracture to the collar bone (clavicle) of the child during birth. 
  • Genetic birth defects: For example, webbing of the neck deformity seen in various syndromes, including Turner’s, Klippel-Feil, or Escobar-Syndrome. Brachial cleft cysts, vertebral bone problems, odontoid hyperplasia, spina bifida, hypertrophy or absence of neck muscles, and Arnold-Chiari syndrome.

Acquired Torticollis

This condition clinically presents because of other problems that affect the musculoskeletal structures of the neck. It typically occurs in the first 4 to 6 months of childhood or later affecting both children and adults. 

Reasons for Acquired Torticollis

  • Idiopathic or Unknown cause: Also classified as “Dystonia” which is a disorder characterized by involuntary muscle contractions that cause slow repetitive movements or abnormal postures. It is unclear but believed to occur due to lesions in an area of the brain (thalamic lesion). 
  • Postural problem: The problem with neck muscles can arise from a prolonged incorrect posture of the neck. It may appear overnight when, for example, a person has slept with his/her neck in an awkward position. Other activities like holding the telephone between the head and shoulder, or playing an instrument, such as the violin, for long periods.
  • Vision problem: Problem with vision in one eye can cause the individual to tilt his or her head to see better affecting the neck muscles on one side.
  • Trauma: Sudden accidental bend or twisting of the neck too far. Whiplash injury of the neck.
  • Infection: Inflection of upper respiratory, ear, or sinus lead to inflammation of the cervical lymph nodes that can irritate the nerves supplying the neck muscles causing torticollis. It can also damage the soft tissues and cause improper alignment of the neck bones.
  • Arthritis of the neck joints: Inflammatory joint conditions like cervical spondylitis, intervertebral disc problems of the neck can also cause torticollis.
  • Side effects of certain medications: Inflammation caused by many antipsychotic and antiemetic medications can cause Spasm or dystonia of the neck muscles.  
  • Neurogenic abnormalities: Spinal cord tumor or progressive spinal cord diseases can cause problems in the neck region. 

Signs and Symptoms of Torticollis

  • Inability to move the neck with limited range of motion
  • Chin tilted to one side
  • Headaches
  • Head tremor
  • Neck muscle spasm and pain
  • One shoulder is higher than the other
  • Spasms in other areas of their head such as their eyelids, face, or jaw, as well as in their hands
  • Stiffness of the neck muscles
  • Swelling of the neck muscles (possibly present at birth)
  • Other neurological signs: Difficulty in speaking, drooling, respiratory problems, swallowing difficulty (trouble initiating), tingling sensation in the neck, upper back and arm due to nerve problems, depression, self-consciousness.

When to seek medical care?

Congenital torticollis can be easily identified after childbirth and determine  the severity of the condition related to its neurological involvement. If a child or an adult suffers from neck problems, it is best advised to seek treatment immediately to prevent worsening of the pain and to prevent the development of torticollis.  

How is torticollis diagnosed?

A thorough assessment of the condition related to the history of the individual will be taken. Any injuries to the neck can be detected by certain diagnostic tests like an X-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI).  However, it’s unlikely that the exact cause of the muscle spasm can be isolated.

In children and infants, experts can detect neck muscle damage that may cause torticollis through routine physical examination. Newborns will be assessed for the presence of neck and/or facial or cranial asymmetry within the first 2 days of birth through visual observations.

How can torticollis be treated?

Treatment should begin immediately for infants with torticollis. At this stage, it is most successful in reversing the deformities caused by torticollis. For example, as the child grows with torticollis, the face on the tilted side may become flattened. This flattening can be reversed while the bones are young and soft but after one year of age it is most likely that the bones get fused and the deformity may become permanent. 

Other problems with delayed treatment 

  • Difficulty learning to walk and frequent falls seen because the head tilt causes unequal weight bearing and loss of balance.
  • Open mouth posture with the tongue pulled to one side or the other.
  • Suck/swallow may be affected leading to feeding issues.
  • A permanent trunk and facial asymmetry can occur.

 Chances of torticollis relapse

Most cases of muscular torticollis have good outcomes, however, there is a chance of relapse with both non-surgical and surgical treatments. Sometimes even if the recovery is spontaneous with continued treatment, there may still be a possible head tilt of small degree.

The outcome will also differ depending on the severity of the injury to the soft tissue and joint structures of the neck.

General goals for treatment,

  • Reducing pain, spasm and muscle strains of the neck.
  • Improving mobility and flexibility of the soft tissue structures affected.
  • Reducing stiffness in the neck and mobilizing the joints of the neck.
  • Postural correction and awareness by changing or selecting positions that will be beneficial for the neck.
  • Functional exercises to the neck muscles to restore stability, strength, and mobility of the neck.
  • Reassurance and education to prevent emotional stress, providing support to cope with social embarrassment.

There is no sure way to prevent wryneck and congenital torticollis; however, utmost care should be taken to avoid trauma to the child as much as possible during delivery. 

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Common Injuries of the Achilles Tendon

Ankle, Common conditions, Exercise, Foot, Injury, Lifestyle, Pain

Achilles tendon injury

The thickest and the strongest tendon in our body is the tendon of the calf muscles of the leg also known as the “Achilles tendon”. 

achilles Tendon main

Fig 1: Calf muscles and Achilles tendon

As shown in Fig 1, the calf muscles of the leg include the gastrocnemius and the soleus muscles that tapers and merges with a tough connective tissue of the Achilles’ tendon. The Achilles tendon then inserts into the heel bone (calcaneus).  Functions of the Achilles Tendon

  • Downward Movement of the foot: When the calf muscles contracts and pulls the Achilles tendon it causes the foot to push downward. This contraction enables: gait, standing on the toes, running, and jumping.
  • Bending the knee: The gastrocnemius muscle helps in bending the knee (flexion) during walking and running.
  • Transferring body weight: With each step of walking each of the Achilles tendon help to distribute the person’s body weight. Depending upon the speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subjected to approximately 3-12 times a person’s body weight.
  • Ankle stability: Along with the other muscles of the leg the Achilles tendon contributes to the stability of the ankle joint.

What surrounds the Achilles tendon? The Achilles tendon is protected by the Achilles tendon sheath and bursae. The sheath is the covering of the tendon that protects the tendon from friction and allows smooth movements. Similarly, the bursae around the Achilles is a thin fluid-filled sac that help to reduce friction between tendon and other tissue areas of the heel.

achilles Bursas

Fig 2: Bursae around the Achilles tendon

As shown in Fig 2, there are two bursae present at the heel. One of the bursae is present in between the surface of the tendon and the surface of the calcaneus at the distal attachment of the Achilles tendon. It is called the “retrocalcaneal bursa”. The other bursa is present between the calcaneum and the skin and is called as the “subcutaneous calcaneal bursa”. 

Brief History on Achilles tendon injuries

Because of the Greek Achilles legend, the Achilles heel is known as a vulnerable part for injury. Hippocrates described that “this tendon if bruised or cut causes the most acute fevers, induces choking, deranges the mind and at length brings death”. It was first reported that a ruptured tendon was to be wrapped with bandages dipped in wine and spices. Since then the cause and treatment of Achilles tendon injuries have brought growing interests among many researchers. 

What causes an Achilles tendon injury?

  • Overuse injuries

This is mostly sports related and is due to overuse of the calf muscles causing an injury to the Achilles tendon. Overdoing or rapid action of the calf muscles or resuming too quickly after a layoff can stress the Achilles tendon. For example, while running or walking faster, up and down on steeper hills or stairs  more powerful movements such as lunges, jumps, or push off.

  • Misalignment and muscle imbalances

Short or tight Achilles tendons or calf muscles, unequal leg length, over or under arched foot, disproportionally weak calf muscles.

  • Improper Footwear 
  • Side effects of certain medications  

Medications (Quinolone / Fluoroquinolone and Cortisone) can weaken the Achilles tendon and this may lead to an injury. Cortisone shots in or near the Achilles tendon may reduce pain in the Achilles tendon, but the weakness in the tendons persists which can an injury during activities.

  • Accidental trauma
  • Inflammatory conditions

Achilles injury may occur in relation to inflammatory illnesses, such as ankylosing spondylitis, reactive arthritis, gout or rheumatoid arthritis.

  • Genetic 

Individuals with a genetic predisposition like hypermobile people are reported to be more at risk of developing Achilles tendon problems. This is because they have excessive laxity in  ankle joints that lead to the wear and tear of the Achilles tendon. 

Achilles tendon injuries

achilles tendon injury locations

Fig 3. Locations of injury

As shown in Fig 3, different types of Injuries to the tendon can occur along different locations of the tendon. 

Musculotendinous junction: This explains the junction between the calf muscle and the Achilles tendon.

Mid portion of the tendon: This explains an injury midway between the top and bottom of the Achilles tendon.

Insertional Achilles tendon injury is an injury at the bottom of the Achilles tendon, where the Achilles tendon connects with (inserts into) the heel bone.

Non-insertional Achilles tendon injury means an injury to any part of the Achilles tendon except at the Achilles tendon – heel bone connection.

Types of Achilles injuries

The spectrum of Achilles injuries ranges from an acute inflammatory irritation to severe cases of rupture of the tendon as shown in Fig 4. The types of condition may co-exist depending on the severity of the injury.

Achilles Tendon course of injury

Fig 4: Types of Achilles Tendon Injuries

Tendonitis and tenosynovitis

Achilles tendonitis is an acute inflammation of the Achilles tendon as shown in Fig 5. Tenosynovitis is an inflammatory condition of the Achilles tendon sheath, rather than an inflammation in the Achilles tendon itself.

Tendonitis insertion

Fig 5: Achilles Tendonitis

Achilles Tendinosis (Tendinopathy): This is the degeneration and micro tears of the Achilles tendon that occurs over time due to overuse of an already inflamed and weak tendon (Refer Fig 6).

Both Achilles tendonitis and tenosynovitis can occur in parallel with, or lead to Achilles tendinosis.

Print

Fig 6: Tendinosis of Achilles tendon

Tendon Ruptures (Partial or complete tendon tear) Achilles tendon rupture is often described as an abrupt break with instantaneous pain that is felt in the foot or heel area. It occurs rapidly while performing activity like running or standing on the toes, which generates intense force on the tendon, leading to partial or complete rupture as shown in Fig 7.

Rupture complete

Fig 7: Complete and partial tear of the Achilles tendon

What can happen if you have an Achilles tendon injury?

  • Pain and tenderness along the Achilles tendon and at the back of the heel that worsens with activity.
  • Thickening of the tendon
  • Bone spur formation at the insert of the tendon
  • Bruising and Swelling around the tendon area.
  • Fibrosis and scarring may be seen in Achilles Tenosynovitis and tendinosis.
  • Restriction of Achilles tendon’s motion within the Achilles tendon sheath.
  • Bursitis: Inflammation of the bursas around the Achilles tendons.
  • Snapping or popping noise can indicate a tendon rupture.
  • Difficulty in moving the foot or pointing your toes (in complete tears of the tendon)
  • A limp may be seen on weight bearing immediately after an Achilles tendon rupture
  • Ankle instability
  • Nerve or blood vessel damage: Signs include numbness, tingling, pins-and-needles sensation in your foot and bruised skin.

How is an Achilles tendon injury diagnosed? An initial examination of the ankle can help differentiate a tendon rupture from other types of injury. When an Achilles tendon rupture occurs, it will not be possible for the individual to stand on toes as shown in Fig 8.

achilles tendon rupture and normal

Fig 8: Achilles tendon rupture of the Left heel

 An MRI or X-ray investigation can also be taken to further confirm the severity of the injury and differentiate the type of injury to the tendon. For example, an MRI scan of a ruptured Achilles tendon is shown in Fig 9.

Complete tear MRI

Fig 9: Achilles tendon rupture

When to seek expert care?

If you felt a sharp pain like a direct hit to the Achilles tendon or if you heard a distinct snap at your Achilles tendon, it calls for a medical emergency. If you have just begun with pain in the back of heels with swelling or discomfort in the Achilles tendon, it would be wise to seek expert assessment and treatment care. What may seem like a mild inflammation may lead to degeneration and rupture. Thus, an initial treatment for tendonitis will not only reduce problems of the tendon but will restore its strength and function which is important to prevent worsening and recurrence of the condition.  

Ankle Injuries – Sprain, Strains and Fractures

Common conditions, Exercise, Injury, Lifestyle, Pain

Ankle sprain main

An ankle injury is the most common type of injury that may involve the bones of the ankle and other soft tissue structures. Three are three types of injuries that are observed at the ankle:

  • Sprains
  • Strains
  • Fractures

Sprains are injuries to the ligaments that connect one bone to another. An ankle sprain may involve an injury to one or more ligaments that stabilize the ankle and the foot. 

Strains are injuries that involve musculotendinous (muscle and tendon) structures. Both sprains and strains can occur due to over-stretching or tearing of the ligaments and tendons due to sudden twisting of the ankle joint or when excessive forces are applied on them.

Fractures are injuries that involve bones of the ankle joint. It ranges from a simple break in one bone to several fractures, which causes your ankle to move out of place and puts you in great pain.

Who could be at a risk of an ankle injury?

Ankle injuries may occur among,

  • Dancers
  • Sports persons- Gymnasts, basketball players, players participating in jumping sports etc.
  • Women wearing unstable high heels
  • Hypermobile people who already have laxed ankle ligaments 

Types of Ankle injuries

  • Lateral ankle injury

This is the most common injury to the ankle. Often, an inversion sprain could be an associated with a fracture and a strain to the peroneal tendons.  

An inversion sprain happens when the ankle in twisted inwards with an inward rolled foot as shown in Fig 1.

inversion injury

Fig 1: Lateral ankle injury

  • The Medial ankle injury

This type of injury occurs at the inner aspect of the ankle. Like a inversion sprain, the eversion sprain may also be associated with fractures of lower ends of the leg bones and strains to the tibialis anterior muscle.  

Eversion sprain happens when the ankle is twisted out with the foot rolled outwards as shown in Fig 2.

eversion injury

Fig 2: Medial ankle injury

High Ankle Injury

This type of injury is very rare. A high ankle sprain happens when the tibia bone rotates injuring the ligaments that hold the lower end of the two leg bones (tibia and fibula) as shown in Fig 3.

Severe injuries may cause fracture to the lower ends of the leg bones.

syndesmosis injury

Fig 3: High ankle injury

Severity of an ankle sprain 

An ankle ligament sprain can be graded according to the severity of the tear in the ligaments as shown in Fig 4.
 
lateral ankle sprain

Fig 4: Grades of ankle sprain

Sign and Symptoms of Ankle Injury
 
    • Swelling: Increased fluid in the tissue due to inflammation and soft tissue damage.
    • Pain:  Depending upon the severity of the injury and the structures involved, pain intensity can vary. 
    • Redness/ Warmth/ Tenderness: Caused by increased blood flow to the area.
    • Unstable ankle: The affected side feels weak and difficult to weight-bear.
    • Deformity: Severe injuries can cause fractured bones to move out of place and make the ankle look deformed.
Causes of Ankle Injury
Trauma
  • Stepping in a hole or a stone
  • Running on uneven ground
  • Fall or slippage on wet floor
  • Contact injury during sports like basketball, when a player is accidentally hit by an opponent causing the foot to roll inwards as shown in Fig 5.
Basketball

Fig 5: Lateral ankle sprain during basketball

Muscle imbalances

Lack of flexibility in muscles can hamper joint movement. For example, if the calf muscles are very tight, it will affect the stability and mobility of the ankle joint. In such a state, if one engages in any physical activity like running there could be a potential risk of twisting an ankle. Sometimes even lack of warm-up and stretching could be the cause of muscle imbalances.

  • Lack of Postural control

Postural control is defined as the act of maintaining, achieving or restoring a state of balance during any posture or activity.

It helps to maintain a good base of support for balance so that the force of gravity can act on the center of mass (COM) of the body. Centre of mass is the point in the body where the entire body weight is concentrated (located in the lower end of the spine) as shown in Fig 6.

Figure_10_03_05

Fig 6: Line of gravity and base of support

During sports, sudden quick body movements or external forces like a push or a contact by an opponent will affect your balance. If you lack postural controlm you may lose balance and risk hurting your ankle. 

Diagnosis of an ankle injury

Most ankle injuries are usually straightforward ligament strains. However, the clinical presentation of subtle fractures can be similar to that of a ankle sprains and these fractures can be easily missed on initial examination. Fractures are usually detected via X-ray scans. If any fracture is left untreated, it may cause excessive pain and disability to an extent that you may not be able to bear weight on the joint. Therefore, an X-ray or an MRI scan is often recommended to understand the severity of the injury.

For example, a lateral ankle sprain showing fractured bones in an X-ray is shown in fig 7. 

ankle sprain with bone fracture

Fig 7: Lateral ankle sprain with fracture of the lower end of fibula bone

Ankle Injury management

Usually, ligament injuries heal in about 6-12 weeks and fractured bones take about 3-6 months to heal. This is however largely dependent on the severity of the injury and lifestyle of the individual so complete healing time frame may vary. 

Even after the healing process, ankle injuries may cause long term instability if not healed correctly. This may also be the cause of recurrent ankle sprains. An expert assessment of ankle mechanics is very important to decide on how long to protect and rehabilitate an ankle after an injury. The treatment plan will aim to restore the normal functions of the ankle and make return-to-play decisions based on the stability of the ankle thus preventing recurrent ankle injuries.

Common Knee Ligament Injuries

Common conditions, Injury, Lifestyle, Pain

17vike0510.jpg

A ligament is a band of connective tissue composed mainly of collagen fibres. The knee joint ligaments connect the femur (thighbone) to the tibia (leg bone) at the knee joint to improve its stability and to limit the amount of mobility in the joint.

The four main ligaments of the knee joint are,

  • ACL: Anterior Cruciate Ligament
  • PCL: Posterior Cruciate Ligament
  • MCL: Medial Collateral Ligament
  • LCL: Lateral Collateral Ligament
knee ligaments

Fig 1: Ligaments of the knee joint

Functions of the knee ligaments

  • Stability to the knee joint

The ligaments of the knee are responsible for preventing the tibia (shin bone) from sliding out of the femur (thigh bone). During rotational movements, knee ligaments work together to prevent both valgus (knee moved inwards) or varus (knee moved outwards) stresses to the knee.

According to their attachments in the knee, the ligaments prevent tibial displacements. For example, ACL prevents forward displacement of the tibia while PCL prevents backward displacement of the tibia. Similarily, the MCL provides support on the inner side of the knee while the LCL provides support on the outer side of the knee.

  • Locking the knee during walking

Apart from supporting the bones, the knee ligaments contribute to the “screw-home” mechanism, a process that locks the knees during walking. For example, just before you strike the heel to the ground your knee is slightly flexed (about 20 degrees bent) then the screw home mechanism works to straighten the knee as your body moves over the planted heel as shown in Fig 2.

swing to stance

Fig 2: Screw-home mechanism

What does a ligament Injury mean?

A ligament injury is the over-stretching or tearing of the ligaments of the knee. A tear may be partial or complete.

mcl injury BY GRADES

Fig 3 Grades of  Ligament injury

What can cause a Knee Ligament Injury?

Extreme movements at the knee joint forcing the knee to move beyond its normal motion can injure a ligament. Most of the injuries occur during weight-bearing activities, as the ligaments resist against perturbations at the knee.

Types of people who usually get them

  • Sports people like football players, basketball players, skiers etc.
  • Hyper-mobile individuals who engage in high-impact sports may have an injury due to excessive laxity in the knee ligaments.
  • Accidental fall on the knees or hit on the knees during contact sports like rugby, football etc or automobile accidents (in which the knees can hit the dashboard)

Mechanism of an injury

hyperextension

Fig 4: Causes of knee injury

  • Hyper extension injury

Extending the knee too far by over straightening of the knee. This can happen when you stop suddenly while running.

  • Flexion and Hyperflexion injury

Jumping and landing on a flexed (bent) knee or falling on your knees with over overbent knees.

  • Rotational injuries

Valgum (inner) or varum (outer) stress on the knees due to twisting of your knee inwards and outwards. Sudden shifting of weight from one leg to the other.

  • Contact Sports

Accidental hit on the knee during sports as shown in Fig 5

PCL INJURY

Fig 5: Direct hit on the leg

Other Reasons that contribute to a Ligament Injury

  • Lack of force distribution

During movement, the body exerts a force on the ground and at the same time, an equal and opposite ground reaction force (GRF) is exerted by the ground on the body. This GRF is directed towards the center of mass (COM) of the body, a point in the body where the entire body weight is concentrated; in front of the tailbone.

If there is an imbalance, which means the athlete’s knee does not bend on landing and remains straight, the GRF creates a forward shear force that pushes the tibial forwards, stressing the ligaments. Hamstring muscles on the back of the thigh play a vital role in stabilizing the knee joint especially when the athlete lands. Normally, the knees normally bend slightly to absorb GRF as shown in Fig 6.

QUADS DOMINANCE

Fig 6: Hamstring action advantage for absorbing GRF

  • Lack of trunk control

Without trunk control, there will be greater movements in the trunk following a perturbation (disturbance) which could affect the distribution of the GRF.

Lack of control in the trunk motion happens because of diminished proprioception. In such a situation, if the trunk moves more on the side of the knee joint laterally, the GRF tracks the COG and follows the movement of the trunk. As the GRF tracks the COM, and if it progresses beyond the center of the knee joint, it results in a movement of the knee joint into a valgus alignment stressing the knee ligaments as shown in Fig 6.

Trunk dominance

Fig 6: Valgus alignment of the left knee

Signs and Symptoms of Ligament Injury

  • Popping sound at the time of injury can indicate a ligament rupture.
  • The knee swelling within the first 24 to 48 hours
  • Tenderness and possibly redness around your knee on touching. 
  • Knee feels unstable or may buckle during weight bearing. This may cause you to limp or feel wobbly at the knee during walking.
  • Bruising around the knee can develop. 

What to do if you think you have an injury?

If you are having any of the above signs or symptoms, seek immediate medical attention. What can appear to be a simple ligament or soft tissue strain may become something more if left untreated. Diagnostic tests such as an X-ray or MRI scan will be able to show any tears or rupture of the ligaments. According to the severity of the ligament injury, appropriate treatment care will be advised.

Temporomandibular (TMJ) Joint and its Disorder

anatomy, Common conditions, Injury, Pain

TMJ

What is the TMJ?

The temporomandibular joint (TMJ) or the jaw joint is a synovial hinge type of joint. This joint is responsible for the movements of our mouth that are needed for chewing, biting, talking and yawning.

To achieve the complex movements needed by the jaw, the TMJ has two articulating surfaces which include the head of the mandible (jaw bone) that fits in the articulating socket of the temporal bone of the skull. In order to prevent friction between the two bones, an articular disc sits between the articulating surfaces which moves with the head of the mandible as one unit.

TMJ disc

Fig 1: Normal TMJ when jaw closed

Apart from the disc and articulating structures, there are other supporting structures that provide stability to the TMJ:

  • Joint Capsule
  • Ligaments
  • Muscles

Joint capsule and Ligaments of the TMJ

The capsule is a fibrous cartilaginous membrane that along with the ligaments surrounds the TMJ and attaches all around the articular eminence of the temporal bone, the articular disc and the neck of the mandibular condyle. Both the capsule and the ligaments provide stability to the TMJ during movements. The four ligaments include (Refer Fig 2),

  • The Lateral Ligament (temporomandibular ligament)
  • Sphenomandibular Ligament
  • Stylomandibular Ligament
  • Stylohyoid Ligament
CAPSULE

Fig 2: Showing the attachment of joint capsule, lateral ligament and stylomandibular ligament.

Muscles around the TMJ

The are four main muscles (Refer Fig 3) of the TMJ are,

  • Temporalis
  • Masseter
  • Medial Pterygoid
  • Lateral Pterygoid
muscles of tmj

Fig 3: Prime muscles for TMJ movement

Movements at the TMJ

There is a combination of hinge and sliding motions that can occur in the TMJ due to the movements of the mandible.

  • Protraction (forward) and Retraction (backwards)
  • Elevation (upward) and Depression (downward)
  • Lateral deviation (Side to side movements of the jaw)
MOVEMENT PROTRACTION RETRACTION

Fig 4: The forward and backward movements of the jaw

ELEVATION DEPRESSION

Fig 5: Upward and downward movements of the jaw

lateral deviation

Fig 6: side movement of the jaw

Temporomandibular Joint Disorder 

  • Muscular problem: Pain and discomfort in the muscles of the face during jaw movements.
  • Disc problem: Usually comprises of displaced disc, dislocated jaw, or injury to the mandibular condyle.
  • Joint problem: Degenerative inflammatory joint condition like Arthritis at the temporomandibular joint.

Reasons for TMJ Disorder

  • Genetics

Individuals who have misaligned jaw or teeth which are hereditary can be affected with TMJ disorder.

  • Functional mandibular overload

Normally the jaw is free to move and make contact with the teeth in the right position, (centered occlusion), in anatomical and functional harmony.

Mandibular overload occurs when one sleeps in a wrong position (face down) where the load of the head pushes the mandible to compress the TMJ on one side and attenuation of the ligaments on the other side. Compression obstructs the blood circulation and moves the teeth to a lateral bad occlusion position. In such a situation, swallowing causes the masticatory muscles to overwork to centre the jaw and bring the teeth from forced lateral malocclusion to centred occlusion. This causes a disharmony between the upper and lower teeth. An imbalance of the jaw that can cause bruxism in an attempt to re-position the teeth.

The term bruxism is defined as an involuntary rhythmic or spasmodic non-functional gnashing, grinding or clenching of teeth. The rubbing causes tooth facet to wear out, structural and function damage to the capsulo-ligamentous and muscles around the TMJ. Stress and psychological problems could worsen the condition.

Sudden trauma

Whiplash injury occurs any time when the head is suddenly and unexpectedly distorted from the neck, causing overstretching of the muscles and ligaments that hold the neck and head in alignment. During a whiplash injury, there is also a potential secondary injury of whiplash in the jaw. Jaw dislocation in severe cases can also occur.

  • Inflammatory diseases 

Sometimes infection in the teeth or adjacent structures can cause a spread of infection in the TMJ leading to infectious arthritis.

TMJ could also be affected by osteoarthritis that causes damage in the articular cartilage of the joint and disc degeneration leading to friction between the bones causing inflammation and pain. It usually affects individuals above 50 years of age and is associated with trauma and other muscular and teeth problems.

TMJ disorder could also be present among individuals who are already diagnosed of rheumatic arthritic disease.

Symptoms of TMJ

  • Jaw pain: Pain and tenderness in the jaws. Increasing pain during chewing in the TMJ and in the muscles, radiating pain is also felt in the face, jaw, or neck.
  •  Limited or painful jaw movement: Swelling due to the inflammation lead to joint stiffness and limited movement, wear and tear of the disc leading to locking of the jaw and impaired jaw function.
  • Headache, Neck pain or stiffness: It is generally assumed that headache, neck pain, or painful jaw movement is suggestive of muscular problems. Masticatory and neck muscles may show muscle spasm and myofascial trigger points in the masseter or sternocleidomastoid muscles that refer pain to the head.
  • Clicking or popping: This occurs within the joint during mouth opening and may indicate displacement of the intra-articular disk during mandibular movement.
  • Ear pain and tinnitus (Ringing of the ear): Middle ear muscles have a common embryological and functional origin with masticatory (Chewing muscles) and facial muscles.Having said that, problems with muscles in TMJ disorder could affect the middle ear. In case, other ear problems are not the cause of ear pain and tinnitus a temporomandibular joint dysfunction may be the reason of these symptoms.

Prevention and Treatment

In order to relieve pain and restore the function of the TMJ, a thorough assessment is required to correctly determine the causative factors and to treat the involved structures. Personalized care interventions at an early stage that includes behavioural change and reassurance are important steps for prevention of TMJ disorder.

Rotator Cuff Injury

Common conditions, Injury, Pain

shoulder

Our shoulders are the most movable joints in our body. Most activities whether simple or strenuous engage both our shoulders. That is the reason why with a little bit of pain in our shoulders, we find it very difficult to do even the simplest of tasks like putting on a coat or carrying groceries. Sometimes there is a crunchy sensation or you may hear clicking and popping sounds while you move your shoulder or do weights. This pain can worsen making you feel frustrated, leaving your shoulders feeling weaker than normal and stiff to move. There could be many reasons for the cause of your shoulder pain but the most common injury that could possibly show these type of symptoms would be a rotator cuff injury.

What is the rotator cuff and how does it get injured?

Rotator cuff injury

The Rotator cuff is a group of muscles coming from the shoulder blade and ending in tendons that attach to the arm bone. These muscles cup the shoulder and are responsible for its stability during movement. The muscles of the rotator cuff muscles include:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor

“Centralisation”- Your rotator cuff is important

The function of the rotator cuff, in addition to generating torque, is to dynamically stabilize the shoulder joint. It keeps the ball of the shoulder centred over the small glenoid socket. Thus, stronger rotator cuff muscles result in the better glenohumeral joint stabilization and hold the humeral head into the glenoid by depressing it. This prevents impingement and decreased chances of shoulder dislocation when the deltoid abducts(arm sideways up) the shoulder. Without an intact rotator cuff, particularly during the first 60 degrees the ball of the shoulder would migrate up the glenoid cavity causing the rotator cuff attachments to get compressed by the acromion leading to impingement of the rotator cuff. In patients with large rotator cuff tears, the humeral head is poorly depressed and can migrate cephalad during active elevation of the arm.

Rotator cuff injuries

Sometimes sudden fall or high impact sports could be the cause of injury but in most cases, it is due to the repetitive injury over the tendons as they being pulled beyond their capacity to stretch. This gradually worsens causing partial or full tear of the tendons. Due to the way these tendons cup the shoulder by being closely spaced, they are more at risk of friction. Especially when you turn your shoulder or lift any weight at the end range of shoulder movement, the tendons in this tight space become taut and rub against the bony knob (acromion process of the scapula) above them or against a ligament at the front of the shoulder. This causes friction, pain and as a normal response, inflammation sets leading to pain, swelling and movement restriction.

Physiology of rotator cuff damage

1. Tendonitis (acute Inflammation)

Tendonitis can occur in a particular rotator cuff tendon causing pain, inflammation and irritation. If this condition becomes more chronic, more tendons can become involved or it may progress to a tendinosis (degeneration).

2. Impingement Syndrome (compression of the tendon)

The most common site of impingements is within the “supraspinatus outlet”. This outlet is a space formed by the acromion process of the scapula, the coracoacromial ligament and the upper rim of the humeral head. Subacromial outlet

Impingement within the outlet can be caused by:

  • Thickened Coracoacromial ligament: This can cause impingement by becoming thickened due to excess calcium deposits that will compress the supraspinatus tendon.
  • Hooked acromium: In repetitive overhead activities, the tendons rubs against the acromion process of the Scapula and gets damaged. When the inflammation spreads into the pocket of fluids (subacromial bursa) that lubricates the rotator cuff tendons under the acromion bone. This causes subacromion bursistis and the pain gets even worse on movements.
  • Abnormal Scapular Movement: With normal shoulder movement, the scapula moves outward and upwards helping the shoulder to move up

scaphumerorhythm movement

  • In the case of an unhealthy shoulder, the scapula does not move in the same fashion as the healthy shoulder and gets “stuck” in a lower position. This could lead to abnormal movement of the scapula during shoulder movement. Poor scapular movement will cause compression of the tendons in the supraspinatus outlet increasing the chances of impingement of the rotator cuff tendon that goes under it.
  • The picture below shows an unhealthy right shoulder at a risk of impingement, showing improper movement in the scapula.

chances of impingement

3. Rotator cuff tears

A tear is a result of the worsening of the tendon damage. Although an acute fall can tear the rotator cuff tendon, chronic inflammation and degeneration due to impingement is the major cause of tears. This tear can start small and get larger over time due to repetitive use or a re-injury. When a tear occurs, there will be severe weakness and atrophy(loss of muscle mass) of the muscles around the arm and loss of movements of the shoulder. impingement

How is Rotator Cuff Injury Diagnosed?

Pain in the shoulder could be caused by various other reasons like joint injury, capsule injury, nerve problems and many more. A thorough examination of the shoulder should be done to distinguish the injury type. If a tear is suspected in the rotator cuff an MRI or an arthrogram (X-ray of the shoulder joint after injecting a contrast dye) can be taken.

normal

Prevention and Management

A proper diagnosis and plan of management is necessary for the treatment and prevention of rotator cuff damage. Initial treatment would be pain relief, rest and avoiding any activity that aggravates pain in order to enhance the healing process. Further treatments will be decided upon the individual’s condition. Thorough assessment and planning by the experts with an application of knowledge of the condition and correct methods of treatment will promote recovery and prevent injury reoccurrence.

What is Tennis Elbow

Common conditions, Exercise, Lifestyle, Pain

tennis player massaging elbow

You just upped the load of your weight training or might have recently engaged in an activity which was strenuous and involve repetitive movements of the wrist and elbow. This later results in a burning sensation on the outer aspect of the elbow which is painful, sore and very sensitive to the touch. All this describes a condition called  ‘Tennis elbow’ which is more commonly known as lateral epicondylitis among clinicians.

Tennis elbow was thought to be common only among tennis players. However, this condition has been affecting more than just sports people as it is actually common in occupations which involve repetitive forearm rotational activities.

It has been estimated that only 5-10% of cases occur in tennis players. More often than not, recreational players are more susceptible than elite tennis athletes due to improper stroke technique or faulty equipment use.

Pain in the elbow was first described as ‘writer’s cramp’ by Runge in 1873 and later was called ‘Lawn Tennis Arm’ now known as Tennis elbow or lateral epicondylitis. Nirschl and Pettrone in 1979, described the pathoanatomy of the area as tendinosis.

Though the acute stages of tendon injury can have an inflammatory component, chronic tennis elbow is considered as a degenerative pathology rather than a tendonitis. Degenerative in this sense as it is more a failed reparative process of the tendon with associated cellular changes rather than active inflammation causing the pain. Therefore, terms like “tendinopathy” and “epicondylalgia” are more often being used by professionals to describe this painful condition which affects both office workers and sports people alike.

All about Lateral Tendinopathy (‘Pathy’ meaning non-inflammatory disorder) or Lateral Epicondylalgia (‘algia‘ meaning pain)

  • What is the lateral epicondyle of the Elbow? 

The elbow joint consists of three long bones which meet in the middle portion of the arm. The upper arm bone (humerus) meets the two inner bone of the forearm (ulna) and the outer bone of the forearm (radius) to form a hinge joint. The radius and ulna bones are responsible for rotational movements of your forearm.

Lateral epicondyle

The elbow functions to move the arm like a hinge (forward and backward) and in rotation (twisting outward and inward). The outer bone of the elbow is referred to as the lateral epicondyle and is a part of the humerus bone.

  • What are the tendons that attach to the lateral epicondyle?

A tendon is a part of the muscle. Tendon function by joining the muscle to the bone providing leverage to perform a movement.

At the lateral epicondyle, the tendons of the extensor muscles start and runs along the forearm. Extensor muscles again end into tendons that pass over the wrist and attach to your fingers. These tendons cause upward or outward movement of the wrist and fingers.

extensor muscles

Extensor Carpi Radialis Brevis (ECRB) – Commonly affected muscle

When performing movements at the wrist or by holding the wrist downwards with the forearm in pronation (Palm facing downwards). The extensor muscles especially extensor carpi radialis brevis is at its maximum length.

ECRB

As the origin of ECRB muscle lies proximal to the axis of rotation for bending and straightening the elbow, it is subjected to shearing stress and most commonly affected in movements of the forearm and wrist.

extensor_carpi_radius_brevis

What are the causes of lateral tendinopathy or epicondylalgia?

  • Overuse injury

The repetitive motion of the wrist or any activity that requires excessive constant gripping/squeezing can cause injury to the extensor tendons.

Individuals who perform multiple sets of dips, push ups and chin ups can also develop pain and injury. Repetitive exercises that involve excessive wrist extension and forearm rotation stresses the extensor tendon. Especially beginners who are trying to perform exercises which their bodies are not used to. They may be executing these exercises with improper posture, incorrect body alignment or bad technique, which predisposes them to painful symptoms of lateral tendinopathy.

  • Weak Scapula Muscles

In a research study published in Journal of Orthopaedic & Sports Physical Therapy (2015), impairments of scapular musculature strength and endurance in individuals with tennis elbow was found. This suggested that muscles of the shoulder and scapula play a role in movements in the forearm and improving the strength and endurance of these muscles will prove beneficial.

  • Faulty techniques

During Racket sports, the overload occurs at the extensor tendons especially in the backhand stroke that is hit with improper technique. The key is to use the body weight and strength from the shoulder than overloading the forearm extensor muscles alone. In a faulty stroke, the elbow is straightening doing the racket motion. 

In the game of tennis, the following maneuvers can lead to tennis elbow:

1. One-handed backhand with poor form and increased load on extensor tendons.

AIG Open Day 7

2. A late forehand swing resulting in bending the wrist significantly stressing the extensor origin.

BNP Paribas Open - Day 10

3. Snapping and turning the wrist while serving with full power

twisting

  • Faulty Equipments

Racket 

A rigid and small size racket causes more compressive forces on the extensor muscles. Even though a stiff racket gives the player more power and control, a lot of compressive forces affect the forearm. The grip of the racket if too small or too large may require more strength to hold the racket. In both cases, the player may have to grip the racket too tightly to prevent it from twisting, and high grip force may increase the risk of injury.

Strings

High thicker string tension is problematic for the forearm because it reduces the dwell time of the ball on the strings. The lesser contact time of the tennis ball means that the shock of the ball impacts more to the forearm muscles.

Tennis ball

Old, wet and soft tennis balls affect the impact and contact point on the racquet requiring more effort from the forearm muscles during impact.

 What happens if you have an injury?

Tendinopathy is the result of overuse activity of the extensor muscles causing the tendons at the lateral epicondyle to have micro tears and reduce its blood supply. The tendon tissue develops large nociceptors that cause severe pain. Pain substances (substance-P and CGRP) irritates the surrounding nerve fibers to possibly inflame which further adds to the chronic nature of the painful condition. With the amount of pain, stiffness sets in causing weakness in the extensor muscles of the forearm affecting grip strength and daily activities. Chronic degenerative changes are seen in the collagen tissue of the extensor tendons that further worsens the condition.

Considering its severity from mildly irritating to a debilitating chronic painful condition, it can have a significant impact on social and occupational life.

How can you prevent tennis elbow?

If your injury is caused by an activity that involves placing repeated strain on your elbow joint, such as tennis or repetitive push-up workouts, changing your technique may alleviate the problem. Identifying and learning correct techniques, postural awareness and feedback for an experienced coach would be beneficial.

The best advice is to avoid too much stress on the muscles and tendons surrounding your elbow engaging in overuse activities. Mostly the condition is reversible with rest and treatment which will help prevent the condition getting worse.

Having said that, if it’s just an irritation, there are some precautions you would need to consider immediately while playing tennis. Watch out for faulty strokes or a playing situation which seems to exacerbate the problem. Get more information on the racket dynamics, tennis ball type and strings so that you can avoid injuries due to faulty equipment use.

Due to the insidious nature of the condition and a wait-and-see approach by many individuals, this condition becomes more chronic and debilitating. If pain persists and restricts the movements of the elbow, it will be best for you to get your elbow examined by experts to prevent any further damage.

Functions of the Patella – Knee Cap

anatomy, Common conditions, knee, Lifestyle, Pain

knee cap

The only time feeling weak at the knees would be a normal phenomenon is when you are standing at the edge of a cliff or doing a bungee jump.

Experiencing weak knees with joint pain can be quite debilitating. We can sit, stand, walk, run and move about easily because of our knees. What we should know is that our kneecap is a part of the knee joint and it should remain ‘in the groove’  for optimal function.

The kneecap, also called the patella bone, is a sesamoid bone in the front of your knee. It’s called the sesamoid bone as it has the shape of a sesame seed. The sesamoid bone is a bone that grows within a tendon. The patella has many biomechanical functions which are responsible for the protection, support and movements at your knees.

Anatomy of the knee cap

anatomy

The knee joint (Patellofemoral joint) is comprised of the three bones. The thigh bone (Femur), the shin Bone (Tibia) and the patella (Kneecap). The patella  lies in a groove at the lower end of the femur and acts as an attachment point for the four main muscles of the thigh (quadriceps). The lowest part of the patella continues on as a tendon that attaches to the tibia. The muscles pull on the patella and the patella pulls on the tibia allowing you to straighten your knee from a bent position.

knee extension action

Cartilage of Patella

articular cartilage of patella

The cartilage is a taut protective structure underneath the kneecap. It found to be among the thickest cartilage in the body providing cushioning for the patella bone. The cartilage helps to prevent friction and acts as a shock absorber protecting the bony surfaces.

Why is the patella so important?

  • Patella functions as a natural pulley

The kneecap plays an important role, it increases the leverage of the quadriceps tendon (thigh muscle tendon) and protects the front of the knee from direct trauma.

lever arm quads

The quadriceps muscle is providing the force like the man in the picture, the patella bone acts as a fulcrum to provide more leverage for lifting the stone.

In real life though, the patella is a little more complicated by not only providing increased force, but also by aiding in balancing forces as well as providing a direction for the forces.

  • Prevents excessive weight-bearing compressive stress 

As weight bearing stress falls on our knees, the patella acts as a spacer protecting the quadriceps tendon and bone from coming into compression and creating a frictional force. The patella also allows for smoother movements when bending and straightening the leg.

  • Maintaining the Quadriceps Angle

Q angle

The quadriceps angle or the Q angle is determined by drawing one line from the hip bone (anterior superior iliac spine) through the center of the patella and a second line from the center of the patella through the leg bone (tibial tuberosity).

normal Q angle

As the Q angle increases above 15 degrees, it potentially could cause the patella bone to move out of its groove. This is as if the Q angle is increased, forceful contraction of the quadriceps muscle can cause the patella to move outwards and possibly dislocate. Slight changes in the Q angle would cause imbalances in the muscle forces causing compression stress, symptoms of pain and inflammation at the knee joint.

Knee Pain related to the Patella 

Although patellar dislocation, fracture, and patellar tendon inflammation are the common sports-related injury. Many patella related problems may also occur during daily activities.

  • Runner’s knee/ Patellofemoral pain syndrome 

Patellofemoral joint pain is a condition seen in runners causing pain during running or while at rest. Pain usually occurs in the front of the knee.

  • Condromalacia Patellae (“soft cartilage under the knee cap”)

This often affects young, otherwise healthy athletes. Chondromalacia patella is one of the conditions that cause pain in front of the knee. When pain exists in the absence of cartilage softening, it can be referred to as patellofemoral pain syndrome (Runner’s knee). Although it’s common to sporting individuals, it can also affect individuals with weak quadriceps muscles. It is common among individuals engaging in activities like football, cycling, tennis, weightlifting, runners. In other words, any sport that involves running, jumping, squatting and landing on the knees.

  • Prepatellar bursitis (between patella bone and skin)

Prepatellar bursitis has historically been referred to as “housemaid’s knee”, which is derived from a condition that was commonly associated with individuals whose work necessitated kneeling for extended periods of time. Prepatellar bursitis is common in professions such as carpet layers, gardeners, roofers, and plumbers.

  • Infrapatellar Bursitis (Below the Kneecap)

This is common among individuals who engage in activities that involve kneeling down for long hours causing inflammation of the bursa below the patellar tendon. It can also occur conjunctively with a condition called jumper’s knee.

  • Suprapatellar Bursitis (Above the kneecap)

Injuries such as direct trauma and overuse injury to the bursa beneath the quadriceps tendon cause inflammation of this bursa.Overuse injuries caused due to running on uneven surfaces or doing jobs that require crawling on the knees.

  • Osteoarthritis 

Patellofemoral arthritis occurs when the articular cartilage on the underside of the patella wears down causing friction between the patella and the end of the thigh bones. It gets extremely painful during weight bearing with swelling, inflammation around the knee. It is generally a degeneration condition which requires immediate medical attention to manage the condition.

  • Patellar Dislocation 

This type of injury happens when the kneecap (patella) moves out of its groove due to the sudden change in direction engaging in high impact sports. It most commonly occurs among young girls or hypermobile individuals due to laxity and increased hip angle. Direct trauma to the kneecap could also cause dislocations.

As a precautionary measure, using knee pads during sports and regular exercises of your knee muscles will have great benefits for your patella. Generally, most of the injury conditions can be managed with appropriate treatment and rehabilitation.

However, if you’ve only begun to feel pain while doing activities or just by standing, you might like to seek medical attention to prevent long-term pain or further damage to your patella.

 

High Heel Pains – Getting it sorted!

Common conditions, Lifestyle, Pain

painful heel conditions

It’s very tempting to wear that pair of stilettos on party night but going through the same excruciating pain every time you wear high heels could be a sign that you need help. The “long legs” effect is temporal, where the damaging effects of high heels on your back, hips, knees and feet may be long term.

The common complaint is pain. Its source could be from your bones, ligaments, tendons, muscles, fascia, toenail beds, nerves, blood vessels, or even skin.

Considering where the location of your pain and with a thorough assessment of your body, experts can understand and nail the root of your problems.
 

There are various treatments you may want to consider in favour of high heels. Postural correction exercises, joint mobilisation, stretching and strengthening exercises may prove beneficial for your back, hips, knees and ankles.

Types of treatment:

  • Achilles tendon pain

Applying ice on Achilles’s tendon, massaging your foot will increase blood circulation and reduce swelling especially at the back of your heel or the ball of your foot. Ice pack should be applied for a maximum of 10-15 minutes otherwise the effect will be reversed. Ultrasound therapy can also help enhance the healing process of your inflamed tendon by improving circulation.

icing

  • Joint Mobilization

Mobilizing the joints of your body addresses any limitations in movements. This helps short and tight muscles, soft tissue restriction, joint capsule restriction, motor control problems, joint range of motion dysfunction and nerve-related issues.

Ankle joint mobilization therapy of doctor man to woman

  • Tight Calf muscles

Extended wear of high heels may shorten your calf muscles. Therefore, the best way to address calf tightness is to use a heat pack on your calf muscles to reduce pain, soothe and improve its blood supply. You could also use a foam roller to relieve tightness.

wall stretch

Simple calf stretches against the wall would also help, hold each stretch for at least 30 seconds.

Take the support of the wall, with the leg to be stretched kept straight at the back. Bend the front leg leaning into the wall causing a stretch to the calf muscle of the back leg. Hold position and repeat for at least 3 sets.

  • Orthotics for Arch support and Cushioning

bunion splint

You could see a podiatrist and invest in customised insoles if you have heel pain. Otherwise, off-the-rack silicone metatarsal pads will also help to protect your forefoot. You basically want to provide as much cushion to your feet as possible to reduce and absorb impact.

  • Bunions

Applying a cold compress over the bunions will reduce pain and swelling. Padding over the bunion will help prevent friction. Corrective orthosis footwear will straighten the toe and put it in its correct alignment during recovery.

Toe alignment correction

  • Treat Metatarsalgia

Rest, ice and avoid weight bearing. Ultrasound therapy can be used to reduce pain and enhance healing. Metatarsal mobilisation is also recommended for improving the range of motion. Use metatarsal pads for relief of pain while standing.

metatarsal pads

  • Prevent Haglund’s Deformity (the bumps at the back of heel)

Avoid wearing strappy heels. Soft-backed shoes or going barefoot helps reduce the friction around the area. Use heel pads to cushion the heel or underneath the heel to lift it up and reduce pressure when walking. Applying cold compress, doing calf stretches and trying ultrasound therapy over the Achilles tendon attachment will help.

US for bumps

  • Support your foot with Kinesio taping

Kinesio taping is a technique used to support your foot structures and promote the natural healing process without restricting the joint range of motion. It lifts the skin to help with drainage and prevent circulatory swelling.

high heels KT tape

  • Knee and Back Pain

Pain in the front of the knee and low back pain is common due to postural adjustments caused by high heels. A rest from high heels, pain relief treatments, mobility exercises, stretching and posture correction would be necessary. It is best to get professional advice and assessment of your back and knees to help determine the severity of your pain and its causes.

Although there are several techniques to treat the cause of your pain, prevention is always better than cure. In fact, it’s always good to get your pain managed before it gets disabling and cripples your lifestyle.

High Heels – Your Guide to Making the Right Choices

Common conditions, Lifestyle, Pain

kitten heels

What if experts could tell you that high heels could be safe for your feet. Ever noticed that your friend can wear their 3-inch stiletto heels all day without complains while you can barely walk 3 steps in the same height? Well, it’s not because your colleague has a good pair of shoes. It’s actually because you’re wearing the wrong pair!

Things to look out for when buying heeled shoes

Every person is different with varying shapes and feet sizes, making it difficult for experts to give a specific number for the number of inches you can add to your heels. Here are few recommendations that they give depending on the structure of your feet.

Check your ankle range of motion (ROM)

The ankle joint is formed where your leg bone (Tibia) articulates with one of the foot bone called talus. Below the ankle joint is a small fluid-filled cavity called sinus tarsi. The size of the sinus tarsi  determines how much your ankle can move. If the movement of your ankles are restricted due to lack of flexibility in your ankles or due to small sinus tarsi, then wearing high heels would lead to ankle pain.

sinus tarsi

Test your ROM for high heels

In sitting position, straighten your knees and move your ankle from neutral position downwards to know your range of ankle plantar flexion. This range is from 45-55 degrees normally but may vary from person to person.

Print 18_Estes_Pages

If any high-heeled pair of shoes puts your feet beyond your normal range of ankle plantar flexion, then you will start with pains in your feet, knees, hips or back. A simple way is to look for shoes with a platform wedge in the front so you’ll get your forefoot elevated as well.

wedge platform

Correct Fitting Shoes

The Back of the shoes

Ensure that the heel counter fits you properly and fits well at the back of your heel to prevent your feet from slipping out as you walk.  If there is a gap between your heel and the shoe, friction blisters that may form as a result and could lead to Hagland’s deformity.

loose fit shoes

You may also want to pay special attention to the back of your feet when wearing sling-back shoes. Such shoes may rub against the back of your heels, causing pain and inflammation.

The Front of the Shoes

Proper shoe size is crucial to prevent the tip of your toes from hanging off the shoes in the case of open toe shoes. Notice the shape and the size of the toe box. If it is too big, you risk getting friction blisters from over-clenching your toes in an attempt to prevent it from slipping out of the shoe. This will shorten the soft tissues resulting in hammer toes. Shoes that are too tight or small will also put pressure on your toes and heels, leading to painful hammer toes, corns, and blisters.

hammer toes in shoes

The Shape of your heel

The pointy stiletto heel puts more pressure on the ball of your foot while wedged heels, which are thicker, distributes your body weight over a larger area of your foot.  The wedged heel usually has a skinny center with a slightly wider bottom, providing slightly more stability as compared to the pointy stiletto heel.

wedges or stilettos

Contrary to  popular belief, wedged heels are not stable. There’s little flexibility for your feet and you have to lift your whole foot right off the ground to walk, stomping your foot back down afterward.

The position of the heel is another key indicator. Ideally, it should be located right under the heel bone and not at the back of the foot. You are going to be thrown off balance if the heel is positioned too far back.

Pay attention to the “slope” or “pitch” of the heel. 

high vs low heels

2-3 inch Heels

Whether you are at college or working all day, a 2-3 inch comfortable pair of shoes will be enough to support the movements of your ankle and not place it in a vulnerable state for injuries. Kitten heels shoes will not only save you from foot troubles but it will lend a trendy feminine look with your dress. For most women, the recess of the sinus tarsi is moderate. The 2-3 inch heel will have a gradual slope of about 20-30 degrees plantar flexion, therefore, will be more comfortable.

Above 3 inches

Some 3.5 to 4-inch heels will have a straight drop down to the front portion of the shoe putting increased pressure on the forefeet. That is bad for your feet as it overloads the weight on your toes and balls of your feet. Such heels should be worn only occasionally and are definitely not suited for walking as it’s likely to cause foot problems with prolonged usage.

Arch Support

Those who have noticed their sole lays flat on the ground may have excessive movements in their foot joints. This condition is known as flat feet and wearing high heels may feel comfortable as they put your feet in an arched position. However, it’s best to avoid excessively high heels for unstable joints. Similarly, it’s better for people with stable joints to wear lower heels, as long as they are supportive to their arches.

If you choose the right pair of shoes for your feet, painful foot conditions could be avoided. In fact, you could enjoy wearing your heels all day without any problems. A sound advice would be to also avoid wearing anything too flat or too high for extended hours to prevent any damage to your joints and soft tissue structures.