Acute wry neck or torticollis is relatively uncommon and precipitated typically by the sudden onset of significant neck pain which leads to reflex neck muscle contractions and the maintenance of an abnormal neck position. This abnormal posture is known as torticollis and is a sign of an underlying problem of some kind, but this article discusses an acquired torticollis secondary to an acute neck pain of mechanical origin. It is typical for patients to report they woke with severe neck pain and torticollis, with the process often assumed to be secondary to sleeping in an inappropriate position during the night.

Typical initial presentation a high level of neck pain with muscle spasms and the inability to restore the head to the central posture. A few days or up to a fortnight is enough to resolve most of these pains and treatment is analgesia, collar if needed, physiotherapy such as neck massage, neck stretching and neck exercises. When examined a patient exhibiting torticollis will keep their head flexed to the painful side to some degree and also rotated away from the painful side. The usual symptoms are stiff neck, limited range of motion and neck and scapular pain, with onset often sudden such as when hair drying with a towel or turning the head fast.

The first thing a person is aware of is the sudden pain on one side of the neck, often severe and lower in the neck. There may be pain radiating also down over the scapula and out over the shoulder. If a considerable amount of arm pain is present then this should raise the suspicion of a lesion of one of the cervical nerve roots. Nerve root problems are usually somewhat slower in onset but if the symptoms presented on waking this could be the diagnosis. The outcome is very likely to be just as good as the muscle or joint strain which is more common, but recovery typically takes longer over a period of weeks.

Examination of the patient by a physiotherapist will show a patient who is in some distress from their pain and may find sleeping difficult. They may hold the head carefully to guard against sudden movements of the painful structures. The head posture will be typically abnormal and efforts to restore the posture to normal are rewarded with strong increases in pain levels. The physio will record the neck position and the ranges of movement the patient can perform, with the results in terms of pain. The history will also be taken, to include any previous episodes and what precipitated this event, whether known or not.

It is important to enquire after any arm, scapular, thoracic and shoulder pain. The physiotherapist may need to test the C6 and C7 nerve root reflexes of the biceps and triceps muscles respectively should the situation require this and they may also test the sensibility to light touch of the skin for the same purpose. Muscle strength testing may be omitted due to the likelihood of increasing pain and the probability of an inaccurate result. The physio will include asking the standard series of exclusion questions which allow him or her to conclude the problem is mechanical and not due to medical illness.

The aim of physiotherapy for this neck condition is similar to that for all soft tissue injuries. The first goal is to reduce the pain and inflammation in the damaged tissues and so reduce the resulting muscle spasm which is perpetuating the pain. Anti-inflammatory medications and analgesics may be prescribed as to some extent the pain is the presenting problem rather than some underlying abnormality. Physiotherapists may use ice, immobilisation in a collar and gentle manual traction to attempt to relax the cervical musculature and relieve pain.

Progression on to further therapy techniques is planned once the pain is under control such as neck massage, gentle muscle neck stretches for muscle tightness and mobilisation of the joints. The patient is asked to perform active movements within reasonable pain limits. On restoration of more normal neck ranges of motion and head position the next stage of physiotherapy is to increase the neck muscle strength and endurance so that the person can return to normal.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Cambridge. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

The ability to position the fingers and thumb in precise postures is vital for the highly coordinated use of the hand and the wrist has a significant role to play in this function. The shoulder blade and the shoulder perform the gross positioning of the arm, the elbow places the hand at varying distances from the body, the forearm dictates the angle of the wrist and the wrist performs the final positioning of the hand. The closer to the hand the body parts come the more precise and fine the movement becomes.

The wrist bones are a grouping of eight small bones called the carpal bones and which are arranged in two rows between the metacarpals and the ulna and radius of the forearm. From the end row of carpal bones the metacarpals run down the hand to the junction with the phalanges at the knuckles, making a mobile central hand area. Running virtually parallel to each other and being long and narrow the metacarpals can alter their positioning, either becoming flattened to support something large or rotated round to cup the palm for increased grasping ability.

The neat, close group of carpal bones allows the wrist to perform a conical range of movement facing forwards, with a full 360 degree rotation possible. The bones can move as a group or to some degree individually to permit fine control of the thumb, fingers and hand. The rows are somewhat irregular but on average there are two bones in line with each metacarpal between it and the forearm. This pattern creates a series of joints in line with each other and permits a great variety of individual movements to translate into precise and varied positioning.

The thumb is the most manoeuvrable and astonishing part of the human hand. We possess an “opposable thumb” which is absent from apes and allows us to achieve the high levels of precision movements we require. On the outside of the hand the thumb’s metacarpal is not flat in the same plane as the others in the palm but is turned inwards, giving it the function of crossing the palm to allow the thumb to meet the ends of the fingers in gripping. Much of the specialised thumb movement comes from the junction of its carpal and metacarpal bones.

The movements of the carpal bones can be in unison in small amounts as they move together to allow a movement to occur. As the hands move small amplitudes of movement occur between the individual carpal bones and the carpal rows. The metacarpals are able to rotate around their long axes which allows the palm to be curled into a cupped position. As the palm moulds round to assist gripping it also allows the fingers to align so that they can effectively grip at the correct angle. Any loss of the accessory movements of the carpals and metacarpals can reduce the ability of the hand to function adequately.

The heavy use of the hands in manual work such as lifting and moving large objects, manipulating heavy machines and pulling ropes can damage the function of the wrist. High mechanical forces are generated when the hand grips something hard, squeezing the wrist bones between the metacarpal bones and the radius and ulna of the forearm. This can allow a reduction of the accessory movements between the individual wrist bones. The lunate bone can be moved from its position with painful consequences if the wrist is extended with force.

The commonest reason for the wrist to be extended forcibly is a FOOSH or a fall on the outstretched hand, which can result in a Colles fracture which involves the last inch of the radius and ulna near the wrist. The fracture, commonest in older females, is the most obvious part of the overall injury which results also in wrist sprain and soft tissue injury. Five to six weeks will be enough to heal the fracture but there may be weakness, pain and difficulty with use in the hand for a longer period, partly related to a upset in the inter carpal movements.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Coventry, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

The inward rotation of the femur which occurs as the knee comes close to its locking position of extension is not large but very important to knee function, making the knee much more complex than a simple hinge joint. The small internal movements of the knee are limited in the knee joint and the joint cannot afford any losses of these motions without losing some of its function. These small movements are called accessory movements and are small gliding and sliding movements which occur within the joint during functional activity but which cannot be performed in isolation.

The knee has to satisfy the competing demands of stability and mobility, it has to be a powerful and reliable prop for the body weight and it has to move into varied positions with great speed. In the case of walking the knee must at one moment bear the entire body weight and then the next unlock so that the leg can be lifted to step forward. As the cycle progresses the knees lock and unlock regularly and reliably, enabling rapid walking and the covering of great distances without fear of falling. The slide that occurs during the knee lock and unlock is vital to this function and can give problems early on in knee pathology.

The knee has very strong muscles but can also respond to changes such as an uneven surface by finer controlled reactions. The knee is strong enough to achieve full squatting and then stand our body weight up again without pause. The knee’s accessory movements are small in distance with side to side more limited than front to back, both however contributing to coping with uneven ground. The inside of the knee joint can gap open more than the outside due to the natural angle of the lower leg to the knee.

The first article about the knee covered the idea that the knee moves backwards and forwards and tends to stick in that plane, so if an abnormal stress such as to the side is added this changes the balance in the joint. The kneecap and the main knee compartments can experience wear changes if the knee suffers from bow-leg or knock knee. The knee is divided into two compartments, the medial and the lateral side, both with their own meniscus, ligament, femoral and tibial condyles. The stresses which are transmitted across the compartments vary with changes in the sideways angle of the knee.

If the knee becomes bow-legged to some degree the quadriceps pulling on the patella levers it towards the inside and can cause the patella to be compressed against the inside of the femoral groove, with painful results. The lateral knee compartment then suffers increased forces and is subject to accelerated wear changes on that side. Typically people have a small degree of knock knee, and any exaggeration of this can make kneecap pain more likely on the outside and cause increased wear of the inside compartment.

Patellar problems can also occur if the knee does not typically extend fully, as the knee remains slightly flexed and the quadriceps has to maintain knee stability, pushing the patella strongly against the femoral groove. These increased forces can be a cause of patello-femoral pain which is a very common complaint. If the knee has some abnormal lateral alignment then a small wedge under one side of the heel can realign the foot and shin bone from below and thereby make a very small but important change to the stresses through the knee.

The patella can also give problems in response to abnormal changes in other joints. As we get older our foot arches can become less strong and so less pronounced, sometimes leading towards a degree of flat foot. As the feet rotate inwards on weight bearing the whole foot and shin move inwards to some extent, introducing an amount of knock knee effect at the knee. This can cause the kneecap to glide more outwards along the groove than normal and lead to patello-femoral pain. An effective treatment can be to wear orthotics in the shoes, which can combine restoration of the foot arches with the necessary level of medial wedging of the heel.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Leicester. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Small movements which allow a glide and a slide inside a joint are essential for the normal use of the joint but cannot be done in isolation, occurring with other movements. These are called accessory movements and their presence is vital to joint function, a reduction in available range or a pain problem resulting if they are lost or reduced. The hip is a deep joint with significant stability so the accessory movements are rather subtle, with the main one being compression and distraction, the pushing in to and pulling out of the ball from the socket.

The health and well-being of the articular cartilage are related to the repeated cycles of compression and relaxation applied to the joint such as with weight bearing and walking. The cartilage is pressed downwards to a degree when pressure is applied and this indentation returns to normal once the pressure is relieved. This engages a fluid pumping system where it is squashed out of the cartilage under compression and pulled back in on relief of the pressure. This pumping of fluid from the deeper cartilage and underlying bone keeps the surface healthy.

The production of new cartilage is in response to the daily expected mechanical stresses put on a joint, and with the high forces involved in heel strike the cycle of stresses and relaxation are important to counter this. Encouraging larger movements in greater ranges may be useful to encourage growth of cartilage, however if loads are static or significantly reduced the opposite may occur. Loss of cartilage may occur with continued static loading, high bodyweight and allowing the joint forces to reduce by using a walking aid.

When a joint is painful it may not always be the best idea to rest it although pain will be reduced at least initially. Without normal forces the cartilage regrowth stimulation does not occur and there may be a tightening of the joint capsule and a loss of the full movement of the joint. The joint may then become more painful as the tightness increases compressive forces. Respecting a painful joint is important but overall it is better to keep an arthritic joint moving than to keep it static. The normal cyclical rhythm of gait is very important in maintaining movement and good blood supply to the upper hip area.

In the inside of the hip, leading from the acetabulum to the femoral head, is the band like ligamentum teres which carries blood vessels that can be stimulated by the typical cycle of gait and allow a fluid pump. The may give an improved blood supply to the femoral head and maintain bone health. The normal forces which walking places on the upper femoral region are vital to keeping the bone composition and density within normal ranges. Resting in bed or using a walking aid can both contribute to a reduction in mineralisation and density in bone, making it less flexible and so less able to counter strains and jars.

In western societies we typically use little of the relatively large available ranges of movement of the hip joint. We walk in a limited, repetitive range and when we sit we typically do so at a mostly high level so our hips don’t go beyond 90 degrees flexion. We seldom push our hips to the extremes of movement of which they are capable and this tendency increases greatly with age. Overall the hip will benefit from maintaining a variety of its movements and from placing it at the ends of its ranges at times. Eastern peoples typically squat or sit cross legged, even to iron, and seem to have lower levels of hip arthritis.

An increased tightness in the joint capsule can result from a person not taking advantage of their full joint ranges over a time period, elevating the tendency for the head to be compressed into the socket. If there is a discrepancy in leg length this can primarily affect hip extension as the hip and knee are maintained in slight flexion to keep the eyes and head level. This fixed flexion deformity of the hip limits extension excursion of the joint in walking and changes the pattern of gait.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Windsor, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

Like the elbow, the knee joint is an example of a hinge joint with added complexity. The condyles of the femur are enlarged rounded areas at the base of the femur and they make up the knee joint with the enlarged flattened area of the upper end of the tibia. On the outer side of the shin lies the fibula, a thin, long bone which does not make up part of the knee nor bear much weight, mainly acting as an area of muscle origin for the muscles which move the foot, ankle and toes. The hinge joint of the knee splits the leg in two, allowing tidy folding in resting or active positions, the necessary shortening of the leg to allow effective walking and the large levels of of propulsive power required.

As the knee approaches full extension or straightening the main thigh muscles (the quadriceps) engage to achieve full active extension and guide the knee into its locking position. Apes are unable to straighten their knee in standing, whilst humans can extend their knees fully in standing which allows very low energy usage. As the knee gets closer to full extension the thigh muscle rotates the knee inwards to allow it to reach the locking point. Humans can stand with their knees straight for long periods with little activity in the quadriceps and hip muscles, combining stability and low effort.

Inside the joint are two crescent-shaped structures made of cartilage, looking a little like banked tracks, accommodating the large rounded femoral condyles. Their exact function is not clear but they may contribute to guiding the knee towards locking, stabilise the knee by centring the condyles during bending and straightening and evening out any potential unwanted small movements during joint motion. The kneecap is the other part of the knee joint and is a small bone with an inner lining of articular cartilage which is suspended in front of the knee joint.

The kneecap or patella is placed within the tendon the main thigh muscle or quadriceps, the muscle which enables us to move our body weight up and down stairs and up from a chair. The patella is shaped on its inner surface with two facets, fitting into the groove formed between the condyles of the femur, sliding along the groove as the knee moves. The kneecap is present to allow the muscular forces developed by the quadriceps to be amplified across the knee and so enable application of high levels of power.

When a knee continues to bend and straighten in a forward and backwards direction the alignment is good and problems are less likely to arise. When a sideways misalignment is added however, the knee can develop painful conditions. A sideways alignment (knock knee or bow leg type conditions) throws the stresses onto one side of the knee by compressing that side of the joint, exposing it to increased wear. A misalignment also changes the angles of function of the patella and causes it to track off to one side, increasing joint friction and causing pain.

The high mechanical forces transmitted through the knee are responsible for a variety of knee conditions, often affecting the kneecap or the knee cartilages (more properly called menisci). The knee typically has a range of motion from full extension (stated as zero) to full flexion at around one hundred and forty degrees, depending to some extent on body size and bodily mobility. There is an important degree of internal glide and slide of the femoral condyles as they move on the reciprocally moving tibial surfaces.

The forward and backward gliding of the condyles of the femur ensure that they will not slide off the back of the shin bone during motion. In motion one bone does not move in isolation, rather one bone moves in a complicated manner on a complementary bone which is also moving to complete the overall function. This permits a much larger range of motion than would be achievable without such a technique. The femur exhibits an amount of rotation also at the knee which is most discernible as the knee approaches fully straight and the thigh rotates inwards to lock the knee safely.

Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for Winchester physiotherapy visit his website.