Major joint replacement is one of the success stories of the late twentieth century, providing the greatest changes in quality of life measurements of all medical treatments or operations. Total knee replacement has now developed from a less predictable operation to a routine procedure with good long-term results for severely osteoarthritic joints. Populations in developed countries are rapidly getting older and total knee replacement is set to overtake total hip replacement as the most performed joint replacement.

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Physiotherapy management of knee injuries and knee operations requires a good way of applying cryotherapy to counter the swelling and pain involved. The Aircast Cryocuff gives physiotherapists this option as traditional ways of applying cold are clumsy and not very effective.

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The wrist has a large, three hundred and sixty degree cone of movement facing forwards at the end of the arm, a consequence of the close arrangement of the small carpal bones. Group movements or individual ones between the bones can occur and this allows precise control of the hand, thumb and fingers. The rows are arranged irregularly but in general two of the bones line up with the end of each of the metacarpals. This allows the creation of a line of several joints leading to each finger which enables the separate and flexible movements of the hand.

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Instability of the shoulder in multiple directions is moderately often encountered, occurring normally on both sides of the body and is not related to accident or injury. The underlying difficulty is the laxity of the capsule of the shoulder and the deficiencies of these stabilising ligamentous structures. This ligament laxity shows itself in excessive joint mobility in all anatomical directions. Patients may describe joint instability as the shoulder may sublux (partial dislocation) or wholly dislocate from time to time. However, the patient may not suffer such obvious symptoms and complain only of pain.

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As the calf muscles contract and a person rises up on tiptoes to bring the bodyweight over the heads of the metatarsals there is normally an inward deviation of the heel region. This inward deviation will not be present if there is a significant dysfunction of the tendon of the posterior tibial muscle and the patient may not be able to attain the position or can do so in part and with pain. The physio will move on to palpating the tendon insertion with the leg up on a plinth, searching for swelling, pain or tenderness. To test muscle power the physio will resist the inward and downward action of the foot.

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In ankle impingement there is a limitation in the joint mobility of the ankle due to pain from a soft tissue or bony pathology. A common finding to precipitate this pain syndrome is an irritation of the synovial membrane or the joint capsule, typically after an ankle sprain or a repetitive series of such injuries. Chronic pain in the ankle and impingement can result from the ankle being sprained and this can give a persistent pain problem with limitations on involvement in sports. Numbers are unclear but some level of impingement could occur in about ten percent of people who undergo ankle sprains.

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There are two major classifications of flat foot, congenital flat foot which is often asymptomatic and cannot be classed as a pathology, and acquired flat foot which occurs in adulthood secondary to some pathological condition. The causes of adult flat foot are many and include fractures or dislocations of the foot, abnormalities of the foot, neurological problems and arthritic conditions. The most frequent cause of this acquired form is a dysfunction of the tibialis posterior tendon, the tendon of one of the calf and foot muscles. Trauma to the area, inflammation or degenerative changes can all affect this tendon.

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The expansion of the flat upper end of the tibia which makes up the distal half of the knee joint is known as the tibial plateau. The plateau is an essential part of the weight bearing function of the knee joint and if compromised can severely affect the movement, stability and alignment of the knee, interfering with gait. The fracture should be recognised early and treated accordingly so that the chances of post-traumatic knee arthritis and disability are minimised. Over half the patients in this category are in their fifties or older.

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Meralgia paraesthetica is one of the many localised pain syndromes which can present to a musculoskeletal physiotherapist, with symptoms of tingling, numbness and pain in the anterior and lateral aspects of the thigh. The symptoms were linked with the idea of a local nerve suffering compressive forces not long after its initial description in the 19th century. The lateral femoral cutaneous nerve is the culprit and is solely a sensory nerve, having no muscular function and merely supplying the skin sensibility over the relevant thigh areas. It is not clear how often this syndrome occurs but it is likely to be under diagnosed.

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Our modern habit of confining our feet into the prisons of our shoes may be partly responsible for some of the problems we face. Our feet have evolved to manage the changing levels and types of surfaces as the toes grip the ground and reinforce the arches. With the universal use of shoes almost all of the time we have given our feet a much reduced role and they do not have to be able to manage the ground surface, being given a smooth firm plastic or leather one instead. The small intrinsic foot muscles weaken and lose function as they are deprived of their natural job, reducing the foot’s effectiveness.

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