Monday, 11 December 2017
Those of you who participated in our Facebook teaser may wonder why totting up the number of bones in the picture didn't automatically equate to a correct answer (26).
If you open a basic anatomy textbook (or Google the question 'how many bones are there in the human foot' then this is, indeed, the answer you are likely to get:
• Seven tarsal bones (Medial, intermediate and lateral cuneiforms; cuboid, talus, navicular, and calcaneus).
• Five metatarsals
• Fourteen palanges – the big toe only has two, the other toes have three (actually to an embryologist, they all have three: the medial cuneiform starts life as a metatarsal; the navicular, which forms the keystone of the longitudinal arch, as a cuneiform and the metatarsal in actually an elongated proximal phalanx).
This ignores the fact that othopaedists will also include the fibula and tibia which are functionally part of the foot, being connected to it by the medial and lateral collateral ligaments – the ones you sprain when you twist your angle.
So that's 28.
Or the fact that the majority of adults have two additional sesamoid bones underneath their big toe, like miniature kneecaps.
So that's 30.
These bones can commonly be bipartate, that is formed in two parts – so that makes 31 … or 32 – and other bones can also be formed in two parts.
There are also dozens of of other, less common, anatomical variants including up to twenty other sesamoid bones, of which the most common is the os trigonum followed by other sesamoidal toe bones.
You can also have extra bones – particularly toes (Anne Boleyn famously has six toes and fingers – and a supernumerary nipple – which helped fuel the assertion she was a witch). Extra toes can form in several ways, with a variety of extra bones forming.
And finally …
You are actually born with just 22 bones in your foot. Several of the tarsal bones are still just cartilage at birth that gradually develop into bone as you grow over the first decade or so of life. So children have fewer bones initially; however, some bones have more that one ossification centre, which makes it appear that, at some points in time, they have more than 26 bones … or 30 bones … or (my favourite answer), "lots".
Thanks to all who took part.
Monday, 8 May 2017
Have you got a blooming bad back?
Summer is finally on the horizon: the soil is warming, the cold frame is filling, the plants are hardening off – the question is how are you going to get them in the ground without it hurting?
The tradition method of squatting or bending down and scraping a planting hole with a trowel falls, for many people, into the category of ‘no pain, no gain’. An afternoon of trowel use hurts your wrist and elbows; squatting kills your knees and bending does your back in … but there is a way to fill your borders with flowers and your beds with vegetables without it costing you several visits to a chiropractor.
If you have resisted the temptation to fill every square inch of soil with seedlings the moment Easter has passed, then not only are you going to avoid frosts but your plants are much less likely to get checked by an inclement May – instead of planting out young, tender plants into the soil, pot them on into three-inch pots and harden them off for a couple of weeks.
Not only will you have healthier plants that flower earlier, but this will also enable you to employ a cunning, pain-free method of planting. A three-inch pot pretty much perfectly fills the plug-hole from a bulb planter, and if you invest in a long-handled planter with a foot bar, then it takes very little effort and no bending or digging to make a series of holes into which you can simply drop your mature plants, which then only need to be heeled in.
Another tip is to make sure you keep an edge on the bulb planter – it’s a cutting tool and will go into soil with far less effort if it’s sharp and consider dividing up your planting into twenty-minute sessions: there are plenty of other jobs to be getting on with in between planting out and frequent changes of activity help to avoid physical stress and strain.
It won’t work for absolutely every single plant, but it can be used for everything from runner beans and sweet corn to flowering annuals and box cuttings – and afterwards, you’ll be smiling rather than grimacing!
Tuesday, 7 February 2017
Normally Wednesday is the one working day when I spend the whole day in the same clinic … which means I actually get a lunch hour – or more accurately 56 minutes in which to meet with my practice manager, make phone calls, write emails and do the 1001 other things associated with running four clinics and 4 minutes to wolf down a sandwich.
On some Wednesdays I run a specialist headache clinic with two colleagues – an orthodontist (Mark Brickley) and a psychotherapist (Judith O’Hagan) – in which we get to grips with the complicated sort of problems that cause seemingly intractable head and face pain, but which will often respond to a combined approach in cases where no one individual could hope to be effective (http://www.theheadacheclinic.co.uk/index.html).
Many headaches and migraines come from musculo-skeletal structures (joints, nerves, muscles and ligaments) but if someone is tense, stressed, depressed, clenching their teeth, has an unbalanced occlusion or forward head posture, then they can often undo all a chiropractor is trying to correct within hours … or sometimes even minutes. That’s when identifying the component parts of the problem then treating the mind, balancing the occlusion and preventing the clenching allows the adjustments and exercises prescribed by the chiropractor to start working. Headache clinic days are always great days because you get to work with fascinating people on challenging and interesting patients – I also get to sit down to eat lunch before we start, although this brief period of relaxation is somewhat countered by having to fit three clinics into one day.
This week however, I was not in clinic at all on Wednesday.
Like all regulated healthcare professionals, chiropractors have to complete a minimum amount (30 hours) of continuing professional development every year in order to maintain their professional registration. Even if we didn’t, I would still go to the AGM of the Royal College of Chiropractors … in fact I have been to every AGM since the very first in 1997 (bar last year’s when it was oversubscribed and I couldn’t get a place … so popular and important have they become).
The Royal College of Chiropractors (http://rcc-uk.org) is – and will probably remain – the most important thing that has happened to chiropractic this century. Much like the passing of the Chiropractors’ Act in 1994, which paved the way to statutory regulation, the setting of minimum educational standards, a Code of Practice and protection of title (when I graduated, anyone could style themselves a chiropractor), the granting of a Royal Charter to the College of Chiropractors in 2012 was a pivotal moment … I don’t think may people yet recognise how pivotal.
For the first time, the chiropractic profession has recognised specialists developing their post-graduate skills though Faculties (of Pregnancy & Paediatrics, Orthopaedics & Rehabilitation, Sports & Exercise, Animal Chiropractic and my own area of specialism, Pain). The AGM always kicks off with the Faculty AGM’s … this year’s Pain Faculty was taken up for the most part with development, as befits the College’s youngest faculty.
The discussions were wide-ranging: the new NICE Guidelines for Low Back Pain & Sciatica (https://www.nice.org.uk/guidance/NG59) again include spinal manipulative therapy and exercise and amongst the few therapies that actually work (good news for chiropractors and osteopaths); however, acupuncture is no longer included – although it will, I hasten to add, continue to be offered as part of our treatment packages despite this.
I pointed out to the meeting that the entire basis for the decision was fundamentally flawed: acupuncture has many different schools with very different approaches (we use medical acupuncture – also known as ‘dry-needling’ – to treat myofascial pain syndromes) and low back pain and sciatica are not diseases but symptoms which have many different causes, some of which will respond and some of which may not. (http://docmartin99.blogspot.co.uk/2015/02/sciatica-is-not-only-condition-thats.html)
What can be said with certainty is that myofascial pain syndromes are an invariable part of almost all low back pain, whatever its cause, and there is abundant evidence that dry-needling is highly effective in treating the trigger points responsible for the pain. The Guidelines therefore demonstrate a failure of joined up thinking … so I got volunteered to write an article for the College’s journal explaining this in scientific terms.
The Faculty also needed a Secretary – and as I was going to clearly be doing some writing anyway … I got volunteered for that too.
And I though I’d got better at saying ‘no’!
The afternoon’s programme comprised the President’s Lecture, delivered by Dr Sarah Goldingay (http://humanities.exeter.ac.uk/drama/staff/goldingay/) – always good to hear from the great and the good outside of the profession – and then presentations from researchers being funded by the College … it’s nice when you listen to old friends speaking and think of them as ‘my ex-squash partner', ‘my MPhil supervisor’ or ‘someone I used to teach’, rather than Professor this or Dr that.
It also made me realise how cutting edge much of what chiropractic is now doing can be – and how it contrasts with some elements of the profession (mostly imports from countries which ought to know better but apparently don’t) who regard the General Chiropractic Council as a nuisance and want to go on delivering care based on benefit to their bank balance using protocols based on 19th century metaphysics.
I recall an old dentist telling me many years ago when I was still at College that it took dentistry 50 years to move from being an unregulated profession to being fully respectable … we’ve only had 16 years but at least (unlike the dentists) we have our own Royal College setting standards to which increasing numbers of chiropractors aspire.
I for one have reached the stage where my most cherished post-nominals (those long list of letters that professional people put after their name to show how professional they actually are) are the four letters ‘FRCC’ (actually I can put these twice because I am both an ordinary Fellow and a Fellow of the Faculty of Pain, but that would be showing off).
This is for the simple reason that all my other degrees and qualifications are what has allowed me to become a Fellow of the College – and the College stands for the quality, rigour and clinical governance that is, I hope, inherent in our clinics’ daily treatment of patients.
Friday, 25 November 2016
Every New Year, our clinics see dozens of new and existing patients whose Christmases have been ruined by musculoskeletal pain, most of which could have been prevented – it isn't just a pain in the neck, we see backs, shoulders, knees, hips and a host of other problems at this time of the year.
There are a number of factors that lead to the upsurge in cases during December – starting with the dreaded Christmas shopping – a phrase that we all know can sometimes mean different things to different genders.
Everybody is familiar with the stereotypes: women make multiple forays into town to accumulate gifts for children, uncles, aunts, nieces and nephews breaking only for regular cappuccinos; blokes stick their head in the sand whilst getting privately stressed and grumpy, then rely on a mad dash sometime late on Christmas Eve.
There is, of course, a compromise to be struck: loath though I am to lift a finger towards Christmas until Advent is upon us, if I see a gift that fits the bill perfectly, I don’t let the fact that it’s still only November prevent me from buying it … and that’s our first tip to avoid injury: buying in smaller quantities prevents overloading muscles, joints and ligaments.
If, however, you are going in for a major shop then it’s a good time to forget about those 10,000 steps a day and park as close as you can to the shops and make regular trips back to the car to drop off bags before they become too heavy or awkward.
A couple of breaks for a sit-down and a warming, re-hydrating cuppa can also help take the strain off shopping-weary backs –as far as your spine and pelvis are concerned, there is a huge difference between walking at a constant regular cadence, and shuffling through the start-stop of shops: so start with a plan rather than wandering aimlessly, it will mean less time on your feet and less strain on your joints … tempting though it is to search out the best bargains, looking at the same item in half a dozen different stores adds mileage and any savings need to be offset again extra parking time… and a visit to a chiropractor if you’ve overdone it! Five minutes preparation before you leave the house can also be worth a ton of cure:
• Wear comfortable, well fitting, shoes.
– ‘Air soles’ help take strain off backs as well as feet whilst you’re pounding the pavements.
• Don’t bring any unnecessary things with you before you start shopping
– You’ll have plenty to carry, so start light.
• Think about how you’re going to transport stuff.
– Can you use a backpack? http://tiny.cc/2ybcpy
– Carry shopping bags equally on both sides so you’re balanced.
– If it’s heavy, can you get it delivered?
• Mind your posture!
– Don’t let your shoulders slump: walk tall with your shoulders back.
• If something does go wrong…
– We have six chiropractors ready to spring into action
– We are always happy to see someone before anything major goes
wrong, so why not get a winter check-up – an ounce of
prevention can be worth a ton of cure!
Tuesday, 18 October 2016
As with so much in life, clinical routine has its seasonal features: the overindulgence accident at Christmas; the gardener’s back in March after a winter of inactivity – most of these problems have an obvious cause an effect but there is one problem that strikes every autumn … and nobody is quite sure why.
Ask a chiropractor how they know when autumn has arrived and they will tell you it’s the sudden influx of patients with ‘shoulder’ pain – instead of half-a-dozen per week, suddenly it’s more than half a dozen every single day.
Theories as to why range from the ‘cold wintery draught on warm skin’ to the effects of rapidly changing day length on serotonin levels, though no theory has yet been proved (it’s not a well-researched subject). What is, however, seems quite clear from clinical experience is that most of these seasonal symptoms are not shoulder pain at all!
If the pain is across the top of your shoulder or between the shoulder blade and the spine, then the chances are it’s coming from your ribs. Patients often look slightly sceptical on being informed that their ‘shoulder’ pain is coming from their costal joints (the joints between the ribs and the vertebrae) – “surely my ribs are in my chest?” they say. In fact, the top rib actually joins with the base of the neck and acts as an anchor for some of the big muscles that run up the side and back of the neck (which can often feel as if they’ve been ‘pulled’ or ‘cricked’ if the underlying rib is injured). You can easily feel your top (first) rib, it’s the bony lump you can feel at the base of your neck just behind your collar bone … that’s how high they go.
By comparison, most pain that arises from the joints and muscle of the shoulder is typically felt at the top of the arm. either whether the rotator muscle pass under the collar bone and attach to the arms or coming directly from the joint between the collar bone and shoulder blade or from the cartilage, ligaments and synovium of the ball and socket joint.
The other things patients often complain of is that – unlike ‘true’ shoulder injuries – they’ve no idea how they’ve done it: it just “came on gradually”, or, more commonly, they “woke up with it”. That’s because the inflammation in the small joints between the ribs and the spine builds up slowly over several hours, so its not the injury (often from lifting at arm’s length) that hurts, it’s the body’s reaction hours later.
So, if you’ve got a intense ache across the top of your shoulder or feel there's a knife in your back just inside the shoulder blade, then you’re probably suffering from costovertebral syndrome, colloquially known as a ‘popped rib’ … and you may well be suffering: it can be one of the most painful of conditions; fortunately, it is also one of the easiest and quickest for chiropractors to treat, with recovery often in days.
There's also something you can do to help yourself if you’re suffering from seasonal shoulder symptoms, use an ice pack (or wrap some frozen peas in a tea towel) and apply for ten minutes or so every hour (that will reduce the inflammation), then pick up the phone and ask one of our chiropractic experts for confirmation that it’s your ribs and not your shoulder that are the source of the trouble.