Varicose and Spider Veins – What are they and How to avoid them.

anatomy, Common conditions, Exercise, Health

main pic veins

What are Varicose and Spider veins?

Varicose veins are abnormal, dilated blood vessels (veins) caused by a weakening in the vessel wall. They may appear as swollen, twisted clusters of blue or purple veins.

Varicose veins are sometimes surrounded by thin, red capillaries also known as spider veins.

(group of tiny blood vessels located close to the surface of the skin, also called telangiectasias) – Refer Fig 1.

varicose veins
Fig 1: Varicose vs Spider veins

Role of veins and formation of abnormal veins

Veins carry blood back to the heart and have one-way valves that prevent the blood from back-flowing. The calf muscles act as a pump by which the blood is pumped back from the legs towards the heart as shown in Fig 2.

Deep Leg Veins

Fig 2: Normal blood flow through Veins, Calf muscle pump

If those valves of the veins become weak from extended periods of increased pressure and swelling, the blood can back up and collect within the veins. This causes the vein walls to weaken and bulge with blood, causing the veins to appear swollen and twisted as shown in Fig 3.

deformed valves

Fig 3: Normal vs Abnormal blood flow

Who can get it and where does it happen?

Varicose veins and spider veins can occur both in men and women. However, women are known to be affected more than men due to their hormonal predisposition and changes during pregnancy that affect the veins. 

These abnormal veins can develop anywhere, but most often appear on the legs and in the pelvic area because as compared with other veins in the body. This is because, lower limb veins work harder to carry blood back to the heart with forces from the body weight and gravity acting at the same time. This pressure can be stronger than the one-way valves in the veins.

Most varicose veins are seen on the surface of the skin as the superficial veins get swollen with blood collected in it that get raised on the surface and at times above the surface of the skin.  

Signs and Symptoms

Some may not have any symptoms but may be concerned about the appearance of the veins. Symptoms usually worsen after prolonged standing or sitting as the blood pools or collects in the veins of the lower limbs. 

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Fig 4: Swelling, Skin changes and Ulcers due to varicose veins

If symptoms occur, they may include:

  • Tiredness, burning, throbbing, tingling or heaviness in the legs
  • Itching around the vein
  • Swollen legs (Refer Fig 4)
  • Muscle cramps, soreness or aching in the legs
  • Brown discoloration of the skin, especially around the ankles (Refer Fig 4)
  • Leg ulcers (Refer fig 4)
  • Rarely varicose veins can form a painful blood clot, referred to as superficial thrombophlebitis (inflammation of a vein).

Risk factors and causes of abnormal veins

Varicose veins are related to increased pressure in the leg veins or defective valves in the veins.

They can happen due to reasons:

  • Idiopathic: The exact cause of this problem is unknown.
  • Heredity: A family history of varicose veins can put a person at risk of developing abnormal veins.
  • Advancing age: With aging veins can lose elasticity causing them to stretch. The valves in your veins may become weak, allowing blood that should be moving toward your heart to back-flow.
  • Prolonged standing or sitting.
  • Being overweight puts extra pressure on your veins, which means damage to the valves, making them more prone to swell.
  • Pregnancy: Pregnancy increases the volume of blood in your body but decreases the flow of blood from your legs to your pelvis. This circulatory change is designed to support the growing foetus but it can produce an unfortunate side effect — enlarged veins in your legs.
  • Hormonal influences during pregnancy, postmenopausal hormonal replacement therapy and use of birth control pills can cause excessive swelling in the lower limbs that hampers blood flow through veins. 
  • Wearing tight clothes can put pressure on the veins which can cause abnormal blood flow.
  • Injury to the veins due to trauma or accidents.
  • Other health conditions that cause increased pressure in the abdomen including liver disease, fluid in the abdomen, previous groin surgery or heart failure.

How is Varicose and Spider veins diagnosed?

A physical examination of the body especially the legs while the person is standing is done. A Doppler ultrasound scan can also check the blood flow in the veins near the skin’s surface and the deep veins. 

When to seek medical care?

  • Walking or standing becomes painful.
  • Soreness develops on or near a varicose vein
  • Your feet or ankles swell up very frequently.

If immediate care is not taken, symptoms may worsen. Complications may develop if there is an underlying disease in the deep veins or in the perforating veins which connect the deep and superficial veins.

  • Chronic venous insufficiency: Untreated venous problems may progress to a chronic condition of abnormal blood flow through the veins.
  • Venous stasis ulcers that result when the enlarged vein does not provide enough drainage of fluid from the skin. As a result, an ulcer (open sore) may form.
  • Fungal and bacterial infections may occur as the result of skin problems caused by the fluid buildup (edema) in the leg. These infections also increase the risk of tissue infection (cellulitis).
  • Thrombophlebitis: Inflammation of the vein due to blood clot formation.
  • Venous hemorrhage: Bleeding through the veins due to micro-tears and ruptures.

How to prevent varicose veins and its complications?

Lifestyle modifications:

  • Losing weight if you are overweight
  • Exercising regularly (especially walking)
  • Avoiding prolonged periods of sitting or standing
  • Avoid wearing tight-fitting undergarments and clothing that constricts the waist, groin or legs.
  • Avoid crossing your legs while seated.
  • Elevating your legs while sitting and sleeping will help.
  • When you need to stand for long periods, take frequent breaks – sit down and elevate your feet.
  • Do ankle pump exercises as shown in Fig 5.

ankle pumps

If you still develop varicose or spider veins, it is best to seek medical attention to know more in details on exercises and lifestyle changes that can be personalized to your needs.  

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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. 

Mobility vs Flexibity

Exercise, Geeky stuff, Lifestyle

fexibility vs mobility

As professionals, we deal with a wide range of conditions for joints and soft tissue problems. We all work with different methods, approaches and principles. At the end of the day, the truth is, we are all solution driven and we all work to make lives better.

We often come across with words like mobility and flexibility throughout our education and training. Whether you are a physical therapist, an osteopath, fitness trainer or a massage therapist. From a professional perspective, when we look at problems with movements, we immediately think of all the tight structures that are causing any restriction in the range of motion (ROM).

Now, the big question is – is this lack of ROM a mobility problem or a flexibility problem?

Let’s make this clear so that we can consider what’s contemporary for best clinical practice.

Flexibility – “Oh this looks very tight, let me stretch this for you!” 

We often use the word “flexibility” too quickly because it is a very convenient and quick way to communicate with a novice. When you say that the lack of ROM is because of tightness in the muscles indicating a flexibility issue, it implies that stretching all the tight tissues can fix the problem. However, are we really dealing with the underlying issue here?  What we are doing is not addressing the real problem AND only treating the symptoms. What if there is a misalignment in the joints causing impingement or some sort of joint restriction?

What are we missing?

The term ‘flexibility problem’ for all joint restrictions would actually mean that we are looking at the problem from only one perspective. Thus using the word ‘flexibility’ shows a great lack of understanding of the injury itself.

When injured, why do we get tight muscles and soft tissue structures?

Post-injury your muscles involuntarily contract to safeguard the injured site. Contracted muscles get fatigued causing soreness and pain. They also pull on bones compressing joint structures. So over-tight muscles now cause over-tight joints. Tight joints lead to stiffness and can cause more pain. Long-term compression of these joints leads to cartilage damage and joint restriction in ROM. Therefore, if you are only looking at the flexibility problems of the muscles and have been stretching them, you might be favoring the injury and causing more damage. 

If you have a stone in your shoe and it hurts your feet to walk. No matter how much you stretch your foot, when you place your foot back in the shoe, your muscles will instantly tighten up in response to the pain.

Furthermore, when you have painfully contracted muscles protecting the injured area, you also adapt to different movement patterns. This adaptive pattern of incorrect movements only perpetuates the pain of injury through muscular over-contraction causing an increase in joint restriction.

ROM Restriction is a Stability and Motor Control Problem

Every movement of our body is a functionally skilled movement which is controlled by the neuro-muscular system that co-ordinates your joints and soft tissue structures. Simply put, your ability to actively move a joint through a range of motion is not only dictated by the flexibility of the muscles or the mobility at the joint but also by your central nervous system.

Mobility – “What is the restriction?”

Mobility is a correct and intelligent word used by clinicians. When we use the word ‘mobility’, we give a very holistic approach to the problem addressing the stability and mobility control of the body. We look at all the anatomical structures and physiological processes that are possibly affected in the injury process.

So when we say it’s a mobility problem, we address:

  • Flexibility problems of soft tissue structures.
  • Movement problems of the joint due to its structural changes.
  • Motor control problems of the joint due to behavior or protective responses.

Therefore, it is important to recognize that flexibility is crucial but is only one of the components of mobility. There are three solutions to ROM restriction but if we name it as a flexibility problem then there is by definition only one.

The Mobility Approach

Mobility is influenced by the structure of joint, ligaments, capsule, neurological control, behavior, fascia, pain and/or fluid dynamics. Whereas stretching generally focuses on muscles and to a lesser degree, ligaments and perhaps fascia.

Take your finger and pull it back as far as you can safely go, that is flexibility. Now hold your entire finger and the base near the knuckle and circle it in varying ways, the muscles are not stretched but the finger is still moving.

That is improving its mobility, which can influence synovial fluid and joint health.

In the Mobility approach, you look at,

1. Awareness of existing function or restrictions.

2. Releasing or promoting normal mobility through joint mobilization, education of correct movement patterns, correct stage of stretching depending on needs (dynamic, active, passive or active-assisted).

3. Functional stabilization training – prioritizing correct movements and motor-control.