Medicurio

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Muscles play a part in every function of the body. The muscular system is made up of over 600 muscles. These include three muscle types: smooth, skeletal, and cardiac.

Only skeletal muscles are voluntary, meaning you can control them consciously. Smooth and cardiac muscles act involuntarily.

Each muscle type in the muscular system has a specific purpose. You’re able to walk because of your skeletal muscles. You can digest because of your smooth muscles. And your heart beats because of your cardiac muscle.

The different muscle types also work together to make these functions possible. For instance, when you run (skeletal muscles), your heart pumps harder (cardiac muscle), and causes you to breathe heavier (smooth muscles).

Keep reading to learn more about your muscular system’s functions.

1. Mobility

Your skeletal muscles are responsible for the movements you make. Skeletal muscles are attached to your bones and partly controlled by the central nervous system (CNS).

You use your skeletal muscles whenever you move. Fast-twitch skeletal muscles cause short bursts of speed and strength. Slow-twitch muscles function better for longer movements.

2. Circulation

The involuntary cardiac and smooth muscles help your heart beat and blood flow through your body by producing electrical impulses. The cardiac muscle (myocardium) is found in the walls of the heart. It’s controlled by the autonomic nervous system responsible for most bodily functions.

The myocardium also has one central nucleus like a smooth muscle.

Your blood vessels are made up of smooth muscles, and also controlled by the autonomic nervous system.

Did you know?

1. Your heart is considered the body’s hardest-working muscle.

3. Respiration

Your diaphragm is the main muscle at work during quiet breathing. Heavier breathing, like what you experience during exercise, may require accessory muscles to help the diaphragm. These can include the abdominal, neck, and back muscles.

4. Digestion

Digestion is controlled by smooth muscles found in your gastrointestinal tract. This comprises the:

• mouth
• esophagus
• stomach
• small and large intestines
• rectum
• anus

The digestive system also includes the liver, pancreas, and gallbladder.

Your smooth muscles contract and relax as food passes through your body during digestion. These muscles also help push food out of your body through defecation, or vomiting when you’re sick.

5. Urination

Smooth and skeletal muscles make up the urinary system. The urinary system includes the:

• kidneys
• bladder
• ureters
• urethra
• penis or vagina
• prostate

All the muscles in your urinary system work together so you can urinate. The dome of your bladder is made of smooth muscles. You can release urine when those muscles tighten. When they relax, you can hold in your urine.

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6. Childbirth

Smooth muscles are found in the uterus. During pregnancy, these muscles grow and stretch as the baby grows. When a woman goes into labor, the smooth muscles of the uterus contract and relax to help push the baby through the vagina.

7. Vision

Your eye sockets are made up of six skeletal muscles that help you move your eyes. And the internal muscles of your eyes are made up of smooth muscles. All these muscles work together to help you see. If you damage these muscles, you may impair your vision.

8. Stability

The skeletal muscles in your core help protect your spine and help with stability. Your core muscle group includes the abdominal, back, and pelvic muscles. This group is also known as the trunk. The stronger your core, the better you can stabilize your body. The muscles in your legs also help steady you.

9. Posture

Your skeletal muscles also control posture. Flexibility and strength are keys to maintaining proper posture. Stiff neck muscles, weak back muscles, or tight hip muscles can throw off your alignment. Poor posture can affect parts of your body and lead to joint pain and weaker muscles. These parts include the:

• shoulders
• spine
• hips
• knees

The bottom line

The muscular system is a complex network of muscles vital to the human body. Muscles play a part in everything you do. They control your heartbeat and breathing, help digestion, and allow movement.

Muscles, like the rest of your body, thrive when you exercise and eat healthily. But too much exercise can cause sore muscles. Muscle pain can also be a sign that something more serious is affecting your body.

The following conditions can affect your muscular system:

• myopathy (muscle disease)
• muscular dystrophy
• multiple sclerosis (MS)
• Parkinson’s disease
• fibromyalgia

Talk to your doctor if you have one of these conditions. They can help you find ways to manage your health. It’s important to take care of your muscles so they stay healthy and strong.

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Brian R. Mulligan qualified as a physiotherapist in 1954 and gained his diploma in Manipulative Therapy in 1974. He has been the author of numerous articles published in New Zealand Journal of Physiotherapy. He is also the author of two books:

1. “Manual Therapy “NAGS”,”SNAGS”, “MWMS”,etc’ (2003) for Physiotherapists.
2. ‘Self Treatment for the Back, Neck and Limbs’ for Public.

Description

• NAGS- Natural Apophyseal Glides.
• SNAGS – Sustained Natural Apophyseal Glides.
• MWMS- Mobilization with Movements.
• The concept of Mobilizations with movement (MWM) of the extremities and SNAGS (sustained natural apophyseal glides) of the spine were first coined by Brian R. Mulligan

Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient. Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier.

Concept of Positional Fault

• Mulligan proposed that injuries or sprains might result in a minor “positional fault” to a joint causing restrictions in physiological movement.
• The techniques have been developed to overcome joint `tracking’ problems or `positional faults’, i.e. joints with subtle biomechanical changes.
• Normal joints have been designed in such a way that the shape of the articular surfaces, the thickness of the cartilage, the orientation of the fibres of ligaments and capsule, the direction of pull of muscles and tendons, facilitate free but controlled movement while simultaneously minimizing the compressive forces generated by that movement
• Normal proprioceptive feedback maintains this balance. Alteration in any or all of the above factors would alter the joint position or tracking during movement and would provoke symptoms of pain, stiffness or weakness in the patient. It is common sense then that a therapist would attempt to re-align the joint surfaces in the least provocative way

Principles of Treatment

1. A passive accessory joint mobilization is applied following the principles of Kaltenborn. This accessory glide must itself be pain free.
2. During assessment the therapist will identify one or more comparable signs as described by Maitland. These signs may be; a loss of joint movement, pain associated with movement, or pain associated with specific functional activities
3. The therapist must continuously monitor the patients reaction to ensure no pain is recreated. The therapist investigates various combinations of parallel or perpendicular glides to find the correct treatment plane and grade of accessory movement.
4. While sustaining the accessory glide, the patient is requested to perform the comparable sign. The comparable sign should now be significantly improved
5. Failure to improve the comparable sign would indicate that the therapist has not found the correct treatment plane, grade of mobilization, spinal segment or that the technique is not indicated.
6. The previously restricted and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide.

While applying “MWMS” as an assessment, the therapist should look for PILL response to use the same as a Treatment .

• P– Pain free.
• I– Instant result.
• LL– Long Lasting.

 If there is No PILL response, that technique should not be advocated. The second principle is CROCKS

• C– Contra-indications (No PILL response is a contraindication)
• R – Repetitions (Only three reps on the day one)
• O– Over pressure
• C– Communications
• K – Knowledge (of treatment planes and pathologies)
• S– Sustain the mobilization throughout the movement.

Techniques

SNAGs

• SNAGs stand for Sustained Natural Apophyseal Glides.
• SNAGs can be applied to all the spinal joints, the rib cage and the sacroiliac joint.
• The therapist applies the appropriate accessory zygapophyseal glide while the patient performs the symptomatic movement.
• This must result in full range pain free movement.
• SNAGs are most successful when symptoms are provoked by a movement and are not multilevel.
• They are not the choice in conditions that are highly irritable.
• Although SNAGs are usually performed in weight bearing positions they can be adapted for use in non weight bearing positions.

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Headache SNAG

If a patient is suffering from a headache of upper cervical origin then one of the mobilisations or the traction to be described should, as it is being applied, stop the pain. Mulligan assumes that if a headache stops with a manual technique involving the upper cervical spine then, this must be diagnostically significant as to the site of the lesion causing the problem and the fact that there is a mechanical component.

Technique

• Position of Patient: sitting
• Position of therapist: stands beside the patient, while his\her head is cradled between your body and your right forearm (when you stand at his\her right side)
  Application:
  • Start by placing your right index, middle and ring fingers at the base of the occiput. The middle phalanx of the same hand and the little finger lie over the spinous process of C2. Then place the lateral border of the left thenar eminence on top of your right little finger.
  • Gentle pressure is now applied in a ventral direction on the spinous process of C2 while the skull remains still due to the control of your right forearm. (The really gentle moving force to do this comes from your left arm via the thenar eminence over the little finger on the spine of C2).
  • The pressure applied by the index finger moves the lower vertebra forward under the first until the slack is taken up, then the first vertebra moves forward under the base of the skull. This is quickly taken forward until end range is felt and this position is maintained for at least 10 seconds. If indicated the headache will relieve, repeat the HEADACHE SNAG six to ten times. Some patients have a more favourable response when the position is sustained for a much longer time- up to a minute. 

Important, when applying the “ Headache SNAG” the good manual therapist will imperceptibly alter the direction of the glide to effect a change. Small adjustments in direction may be necessary as the true facet plane directions vary between individuals.

NAGs

• NAGs stand for ‘Natural Apophyseal Glides”.
• NAGs are used for the cervical and upper thoracic spine.
• They consist of oscillatory mobilizations instead of sustained glide like SNAGs, and it can be applied to the facet joints between 2nd cervical and 3rd thoracic vertebrae.
• NAGs are mid-range to end range facet joint mobilizations applied antero-superiorly along the treatment planes of the joint selected.
• Useful for grossly restricted spinal movement.
• NAGs for the treatment of choice in highly irritable conditions

Peripheral MWM 

• Once the aggravating movement has been identified, an appropriate glide is chosen. 
• The decision to use weight-bearing or Non-weight bearing movement depends upon the severity, irritability and nature of the condition.
• Once the glide has been chosen it must be sustained throughout the physiological movement until the joint returns to its original starting position
• Mobilizations performed are always into resistance but without pain
• Immediate relief of pain and improvement in ROM are expected.
• If this is not achieved, vary the glide parameters

Spinal Mobilization with Limb Movement (SMWLMs)

• Here a transverse pressure is applied to the side of the relevant spinous process as the patient concurrently moves the limb through the previously restricted range of movement.
• The assumption here is that the restriction of movement is of spinal origin of course.
• This does not necessarily imply neural compromise since spinal movement must occur when a limb moves beyond a certain point.
• Thus the technique addresses a spinal structural/ mechanical restriction, but this may have neural implications too.

MWM for the lumbar spine, sitting

• Extension- Superior anterior force on spinous process, assist with extension with hand on anterior shoulder.
• Flexion- Push superiorly with hook of the pisiform and assist flexion with hand on thoracic back.

MWM for the lumbar spine

• Extension, supine
  • Two hands around the lumbar spine, compress hands (AP and PA force) patient extends back, assisting by pushing up with his hands. *Extension, standing
  • Stabilize with belt, place hand lateral to the lumbar spine, resist patients extension and apply PA force.

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“…the use of hands in a curative and healing manner or a hands-on technique with therapeutic intent…”.

There is a wide range of disciplines which use manual therapeutic methods to treat and manage pathology and dysfunction as a primary treatment method or in conjunction with other treatments. Physiotherapists are sometimes considered specialists in manual therapy but other professions such as Osteopaths, Chiropractors and Nurses employ manual therapy in treatment. Manual therapy works through a multitude of different mechanisms to be effective and understanding the physiological, neurological and psychophysiological mechanisms is critical to utilising manual therapy clinically in a competent and safe manner. 
From a Physiotherapy perspective manual therapy is an essential and commonly used treatment method for the management of tissue, joint and movement dysfunction. There are several different main stream approaches to manual therapy; arguably the most common, simplistic form of manual therapy used by physiotherapists are mobilisations from the Maitland school of thought.

The Maitland Concept

“The Maitland Concept of Manipulative Physiotherapy [as it became to be known], emphasises a specific way of thinking, continuous evaluation and assessment and the art of manipulative physiotherapy (“know when, how and which techniques to perform, and adapt these to the individual Patient”) and a total commitment to the patient.”

The application of the Maitland concept can be on the peripheral or spinal joints, both require technical explanation and differ in technical terms and effects, however the main theoretical approach is similar to both.
The concept is named after its pioneer Geoffrey Maitland who was seen as a pioneer of musculoskeletal physiotherapy, along with several of his colleagues. 

Key Terms

• Accessory Movement – Accessory or joint play movements are joint movements which cannot be performed by the individual. These movements include roll, spin and slide which accompany physiological movements of a joint. The accessory movements are examined passively to assess range and symptom response in the open pack position of a joint. Understanding this idea of accessory movements and their dysfunction is essential to applying the Maitland concept clinically.
• Physiological Movement – The movements which can be achieved and performed actively by a person and can be analysed for quality and symptom response.
• Injuring Movement – Making the pain/symptoms ‘come on’ by moving the joint in a particular direction during the clinical assessment
• Overpressure – Each joint has a passive range of movement which exceeds its available active range. To achieve this range a stretch is applied to the end of normal passive movement. This range nearly always has a degree of discomfort and assessment of dislocation or subluxation should be acquired during the subjective assessment.

Initial Assessment

The Maitland concept is a fantastic tool for approaching an initial assessment as it can be used to form a logical and deduced hypothesis about the nature of the origins of the movement disorder or pain. It is worth considering using mobilisations in your assessment process and reading the Initial Assessment section in Maitlands book Peripheral Manipulation.

As with any treatment decision a competent and effective assessment is crucial to any patient interaction. The Subjective Assessment is necessary for determining whether or not mobilisations are suitable for this patient or if they are contraindicated by looking for red flags such as cancer, recent fracture, open wound or active bleeding, infective arthritis, joint fusion and more. 

The Objective Assessment is an area which the versatile nature of mobilisations becomes clear. Additionally to being a treatment method they are available to the therapist to assess a patients joints and tissues by analysing their extensibility, pain reproduction, bony blocks or abnormal end feels.

Principles of Techniques

Decisions Which Need to be Made

1. The Direction – of the mobilisation needs to be clinically reasoned by the therapist and needs to be appropriate for the diagnosis made. Not all directions will be effective for any dysfunction.
2. The Desired Effect – what effect of the mobilisation is the therapist wanting? Relieve pain or stretch stiffness?
3. The Starting Position – of the patient and the therapist to make the treatment effective and comfortable. This also involves thinking about how the forces from the therapists hands will be placed to have a localised effect.
4. The Method of Application – The position, range, amplitude, rhythm and duration of the technique.
5. The Expected Response – Should the patient be pain-free, have an increased range or have reduced soreness?
6. How Might the Technique be Progressed – Duration, frequency or rhythm? 

How to Choose the Direction

To make sure you settle on appropriate mobilisations it is important to get the type of glide, the direction and speed correct.

Different Types of Mobilisation: How Many Glides?

Each joint has a different movement arc in a different direction to other joints and therefore care needs to be taken when choosing which direction to manipulate; this is where the Concave Convex Rule comes into use, but for now consider the number of possible glides a clinician may use:

1. A-P (Anteroposterior)
2. P-A (Posteroanterior)
3. Longitudinal Caudad
4. Longitudinal Cephalad 
5. Joint Distraction
6. Medial Glide
7. Lateral Glide

Due to anatomical position and other physical limitations not all peripheral or spinal joints can be subjected to all of the types of glide. Here are examples of mobilisations of joints of the body:

• Elbow Mobilizations
• Wrist/Hand Mobilizations
• Hip Mobilizations
• Knee Mobilizations
• Ankle and Foot Mobilisations
• Spinal_Manipulation
• Shoulder Mobilizations and  Manipulation
• Cervicothoracic Manipulation

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Concave Convex Rule: Up, down, Left or Right?

Choosing the direction of the mobilisation is integral to ensuring you are having the desired clinical outcome. This is where a knowledge of Arthrokinematics is important. In summary:

There are two important things to remember:

• When a convex surface (i.e Humeral Head) moves on a stable concave surface (i.e Glenoid Fossa) the sliding of the convex articulating surface occurs in the opposite direction to the motion of the bony lever (i.e the Humerus).

The opposite can be said for 

• When a concave surface (i.e Tibia; talocrural joint) is moving on a stable convex surface (i.e Talus) sliding occurs in the same direction of the bony level. 

Examples:

To improve shoulder flexion you would perform an A-P mobilisation due to the way the convex humerus articulates with the concave glenoid fossa.

An easier way to visualise this is to try and show this rule with your hands. (Picture from)

How to Choose the Grade: How Far into Range and Quickly or Slowly?

Grades of Mobilisations

Grade I – small amplitude movement at the beginning of the available range of movement
Grade II – large amplitude movement at within the available range of movement

Grade III – large amplitude movement that moves into stiffness or muscle spasm
Grade IV – small amplitude movement stretching into stiffness or muscle spasm

**A 5th grade is possible but further training will be required to perform safely**

In many places, you are obliged to obtain a written consent from your patient before applying grade 5 manipulation .

The grading scale has been separated into two due to their clinical indications:

• Lower grades (I + II) are used to reduce pain and irritability (use VAS + SIN scores).
• Higher grades(III + IV) are used to stretch the joint capsule and passive tissues which support and stabilise the joint so increase range of movement.

The rate of mobilisation should be thought of as an oscillation in a rhythmical fashion at:

• 2Hz – 120 movements per minute
• For 30 seconds – 1 minute

Therapeutic Effect: How and Why Does This Work; Mechanisms of Action

There are a number of complex systems which interact to produce the pain-relieving effects of mobilisations, subsequently there is not a single theory into its mechanism. Therefore this article will outline the basics and evidence for the claims and further links will be added for additional more in-depth information. 

Pain Gate Theory

The pain gate theory (PGT) was first proposed in 1965 by Melzack and Wall, and is a commonly used explanation of pain transmission. Thinking of pain theory in this way is very simplified and may not be suitable in some contexts, however when discussing pain with patients this description can be very useful.

In order to understand the PGT, the sensory nerves need to be explained. At its most simple explanation there are 3 types of sensory nerves involved of transmission of stimuli:

1. α-Beta fibres – Large diameter and myelinated – touch and pressure – Fast (50m/s)
2. α-Delta fibres – Small diameter and myelinated – temperature and pain (well localised, sharp/prickly) – Medium (15m/s)
3. C fibres – Small diameter and un-myelinated – pain (dull, poorly localised, persistent) – Slow (1m/s)

The size of the fibres is an important consideration as the bigger a nerve is the quicker the conduction, additionally conduction speed is also increased by the presence of a myelin sheath, subsequently large myelinated nerves are very efficient at conduction. This means that α-Beta fibres are the quickest of the 3 types followed by α-Delta fibres and finally C fibres. 

The interplay between these nerves is important but it is not the whole story, as you can see only two of these nerves are pain receptors α-Delta fibres are purely sensory in terms of touch. All of these nerves synapse onto projection cells which travel up the spinothalamic tract of the CNS to the brain where they go via the thalamus to the somatosensory cortex, the limbic system and other areas. In the spinal cord there are also inhibitory interneurons which act as the ‘gate keeper’. When there is no sensation from the nerves the inhibitory interneurons stop signals travelling up the spinal cord as there is no important information needing to reach the brain so the gate is ‘closed’. When the smaller fibres are stimulated the inhibitory interneurons do not act, so the gate is ‘open’ and pain is sensed. When the larger α-Delta fibres are stimulated they reach the inhibitory interneurons faster and, as larger fibres inhibit the interneuron from working, ‘close’ the gate. This is why after you have stubbed your toe, or bumped your head, rubbing it helps as you are stimulating the α-Delta fibres which close the gate

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Description

Manual therapy has a long history within the profession of physical therapy and physical therapists have greatly contributed to the current diversity in manual therapy approaches and techniques. Mechanical explanations were historically used to explain the mechanisms by which manual therapy interventions worked, new research reveals intricate neurophysiologic mechanisms are also at play and the beneficial psychological effects of providing hands-on examination and intervention should not be ignored.

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) defines manual therapy techniques as: “Skilled hand movements intended to produce any or all of the following effects: improve tissue extensibility; increase range of motion of the joint complex; mobilize or manipulate soft tissues and joints; induce relaxation; change muscle function; modulate pain; and reduce soft tissue swelling, inflammation or movement restriction.”

According to the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) Description of Advanced Specialty Practice (DASP), orthopaedic manual physical therapy (OMPT) is defined as: any “hands-on” treatment provided by the physical therapist.

Treatment may include moving joints in specific directions and at different speeds to regain movement (joint mobilization and manipulation), muscle stretching, passive movements of the affected body part, or having the patient move the body part against the therapist’s resistance to improve muscle activation and timing. Selected specific soft tissue techniques may also be used to improve the mobility and function of tissue and muscles.

Three Paradigms for Manual Therapy Therapeutic Effects

1. Physiological: positive placebo response
2. Biomechanical and Physical: facilitates repair and tissue modelling
3. Psychological: pain relief via- stimulates gating mechanism; muscle inhibition; reduction of nocioceptive activity; reduced intraarticular or periarticular pressure

Techniques Include

• Traction
• Massage
• Trigger Point Therapy
• Active Release Techniques: A practitioner determines where adhesions are through touch, the practitioner then couples a patient’s active movement with his/her touch.
• Assisted Active Range of Motion (AAROM)

• Passive Range of Motion
• Lymph Drainage
• Stretches (muscle, neural tissue, joints, fascia)
• Instrument Assisted Soft Tissue Mobilization

• Joint Manipulation: A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit* with the intent to restore optimal motion, function, and/ or to reduce pain.
• Joint Mobilisation: A manual therapy technique comprising a continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes, that may include a small-amplitude/ high-velocity therapeutic movement (manipulation) with the intent to restore optimal motion, function, and/ or to reduce pain. 

NB The terms “Thrust Manipulation” and “Non-Thrust Manipulation” have been used in the literature.  “Thrust Manipulation” is used to describe interventions described as Manipulation by IFOMPT, and “Non-Thrust Manipulation” would be synonymous with the term Mobilization as proposed by IFOMPT.  

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Guide to Grading of Mobilisations/Manipulations

Maitland Joint Mobilization Grading Scale:

Grade I – Small amplitude rhythmic oscillating mobilization in the early range of movement

Grade II – Large amplitude rhythmic oscillating mobilization in the midrange of movement

Grade III – Large amplitude rhythmic oscillating mobilization to point of limitation in range of movement

Grade IV – Small amplitude rhythmic oscillating mobilization at end of the available range of movement

Grade V (Thrust Manipulation) – Small amplitude, quick thrust at end of the available range of movement

Kaltenborn Traction Grading Scale:

Grade I – Neutralises joint pressure without separation of joint surfaces

Grade II – Separates articulating surfaces, taking up slack or eliminating play within joint capsule

Grade III – Stretching of soft tissue surrounding joint

Additional Viewing

This 28 minute video gives a good overview of the hands-on/off debate and suggestions of when to use manual therapy.

Conclusion

Manual physical therapy is a specialised form of physical therapy delivered with the hands as opposed to a device or machine. It has an important place in Physiotherapy and when used appropriately by practitioners is a very effective set of tools literally at our fingertips.

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The primary goals of manual therapy are:

• Modulate pain
• Increase range of motion
• Reduce soft-tissue inflammation
• Improve contractile & non-contractile tissue repair, extensibility, or stability
• Facilitate movement

Manual therapy is defined as the application of manual forces of the therapist, to change/improve the quality and the range of motion of joints and soft tissues. Mobilisation is a manual technique that through repeated passive motion at low speed replicates normal joint glides at varying amplitudes, while manipulation is defined as fast with a small force, small amplitude and high speed of movement of a joint.

It is hypothesised that manual therapy improves function of the kinetic chain (joints and sot tissue) by a combination of mechanical and neuromuscular mechanisms. In particular in the knee, techniques are aimed at increasing the extensibility of collagen, optimising joint lubrication and reduction of muscle tone which all result in improved joint function and joint mobility.

Indication

The use of manual therapy is supported in the knee.  Indications for the use of manual therapy include:

1. painful neuromusculoskeletal joint disorder
2. pain in or from palpation of bony joint surfaces
3. pain in of from palpation of joint soft tissues
4. decreased or altered range of quality of motion
5. pain on joint movement.

When there is pain in combination with joint restriction, it is recommended to apply manual therapy together with exercise therapy. There is a consensus that manual therapy can be considered as a preparation for exercise therapy by having an effect on pain and joint limitations, and muscle activity.

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Clinical application

A commonly used form of manual therapy applied to joints are oriented mobilisations called ‘joint glides’, these are performed in specific planes of movement and are intended to restore specific movements. Research has demonstrated increased range of movement and function following tibiofemoral mobilisations but these positive effects are only for a short duration and cannot be considered effective for long term outcomes.  This would suggest that mobilisations may be effectively used to promote exercise performance.

Manual therapy is often used in clinical practice for osteoarthritis. Although it is often used, there is little research on the effects of the treatment of knee osteoarthritis independently of other interventions, such as exercise therapy. Studies have shown that manual therapy has a positive effect on the modulation of pain in knee osteoarthritis.  A combination of manual therapy and guided exercises has functional benefits for patients with knee osteoarthritis.  Manual therapy and a guided exercise program can reduce the burden of complaint and postpone the need for surgery therefore reducing cost.

Manipulative therapy of the knee and/or full kinetic chain combined with multimodal or exercise therapy improves patellofemoral pain syndrome Anterior knee pain is associated with the loss of strength and decreased activity of the knee extensors, which refers to a muscle inhibition. Muscle co-contraction around the knee has been shown to improve after joint mobilisations to the knee.  Spinal manipulation may also be regarded as an effective treatment to reduce muscle inhibition in the lower limb musculature

There is little or no evidence of the use of manual therapy at acute knee injury, like ligaments or meniscus injury. For such persons, other appropriate measures in their therapy should be taken such as a supervised exercise programme.

Manual therapy combined with an appropriate exercise therapy seems to be more effective for improving the muscle strength, proprioception and functional performance than exercise therapy alone.

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Joints, also known as articulations, are a form of connection between bones. They provide stability to the skeletal system as well as allowing for specialized movement.

Joints can be classified:

1. Histologically, on the dominant type of connective tissue. ie fibrous, cartilaginous, and synovial.
2. Functionally, based on the amount of movement permitted. ie synarthrosis (immovable), amphiarthrosis (slightly moveable), and diarthrosis (freely moveable).

Generally speaking, the greater the range of movement, the higher the risk of injury because the strength of the joint is reduced

The two classification schemes correlate:

1. Synarthroses are fibrous joints
2. Amphiarthroses are cartilaginous joints
3. Diarthroses are synovial joints

Fibrous Joints

In fibrous joints (synarthrodial joint) the bones are joined by fibrous tissue, namely dense fibrous connective tissue, and no joint cavity is present. The amount of movement allowed depends on the length of the connective tissue fibers uniting the bones. Although a few are slightly movable, most fibrous joints are immovable.

The three types of fibrous joints are sutures, syndesmoses, and gomphoses.

1. Sutures are immobile joints in the cranium. The plate-like bones of the skull are slightly mobile at birth because of the connective tissue between them, termed fontanelles. This initial flexibility allows the infant’s head to get through the birth canal at delivery and permits the enlargement of the brain after birth. As the skull enlarges, the fontanelles reduce to a narrow layer of fibrous connective tissue that suture the bony plates together. Eventually, cranial sutures ossify- the two adjacent plates fuse to form one bone (termed synostosis).
2. Gomphoses are the immobile joints between the teeth and their sockets in the mandible and maxillae. The periodontal ligament is the fibrous tissue that connects the tooth to the socket.
3. Syndesmoses are slightly movable joints (amphiarthroses). In syndesmosis joints, the two bones are held together by an interosseous membrane. Eg Middle Tibiofibular Joint, a fibrous joint formed by the interosseus membrane connecting the shafts of the tibia and the fibula.

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Cartilaginous Joints

Cartilaginous joints are a type of joint where the bones are entirely joined by cartilage, either hyaline cartilage or fibrocartilage. These joints generally allow more movement than fibrous joints but less movement than synovial joints.

• Primary cartilaginous joints: These cartilaginous joints are composed entirely of hyaline cartilage and are known as synchondroses. Most exist between ossification centres of developing bones and are absent in the mature skeleton, but a few persist in adults. eg First Sternocostal Joint, between first rib and manubrium (all other sternocostal joints are plane synovial joints); Growth plates.
• Image 3: synchondroses eg. growth plate
• The secondary cartilaginous joint, also known as symphysis, may involve either hyaline or fibrocartilage. These joints are slightly mobile (amphiarthroses). eg The pubic symphysis: Intervertebral discs.

Synovial Joints

The primary purpose of the synovial joint is to prevent friction between the articulating bones of the joint cavity. While all synovial joints are diarthroses, the extent of movement varies among different subtypes and is often limited by the ligaments that connect the bones. Nearly all joints of the limbs and most joints of the body fall into this class.

A key structural characteristic for a synovial joint that is not seen at fibrous or cartilaginous joints is the presence of a joint cavity. The joint cavity contains synovial fluid, secreted by the synovial membrane (synovium), which lines the articular capsule. This fluid-filled space is the site at which the articulating surfaces of the bones contact each other. Hyaline cartilage forms the articular cartilage, covering the entire articulating surface of each bone. The articular cartilage and the synovial membrane are continuous. A few synovial joints of the body have a fibrocartilage structure located between the articulating bones. This is called an articular disc, which is generally small and oval-shaped, or a meniscus, which is larger and C-shaped.

Physiotherapy

Physiotherapists are qualified health care professionals who are experienced at assessing joints of the human body. See links to below conditions for some examples.

• Arthritis – inflammation that causes stiffness and pain in the joints eg rheumatoid arthritis or gout, or degeneration (osteoarthritis)
• Bursitis – inflammation of the bursae (fluid-filled sacs that cushion and pad bones)
• Tendonitis – inflammation, irritation and swelling of a tendon that is attached to the joint.
• Injury – including strain or sprain of a ligament or nearby tendon or muscle, or bone fracture.

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Biomechanics in sport incorporates a detailed analysis of sport movements in order to minimise the risk of injury and improve sports performance. Sport and exercise biomechanics encompasses the area of science concerned with the analysis of the mechanics of human movement. It refers to the description, detailed analysis and assessment of human movement during sport activities. Mechanics is a branch of physics that is concerned with the description of motion/movement and how forces create motion/movement. In other words, sport biomechanics is the science of explaining how and why the human body moves in the way that it does. In sport and exercise, that definition is often extended to also consider the interaction between the performer and their equipment and environment. Biomechanics is traditionally divided into the areas of kinematics which is a branch of mechanics that deals with the geometry of the motion of objects, including displacement, velocity, and acceleration, without taking into account the forces that produce the motion while kinetics is the study of the relationships between the force system acting on a body and the changes it produces in body motion. In terms of this, there are skeletal, muscular and neurological considerations we also need to consider when describing biomechanics.

Application 

According to Knudson human movement performance can be enhanced in many ways as effective movement encompasses anatomical factors, neuromuscular skills, physiological capacities and psychological/cognitive abilities. Biomechanics is essentially the science of movement technique and as such tends to be most utilised in sports where technique is a dominant factor rather than physical structure or physiological capacities. The following are some of the areas where biomechanics is applied, to either support the performance of athletes or solve issues in sport or exercise: 

• The identification of optimal technique for enhancing sports performance 
• The analysis of body loading to determine the safest method for performing a particular sport or exercise task 
• The assessment of muscular recruitment and loading 
• The analysis of sport and exercise equipment e.g., shoes, surfaces and rackets.

Biomechanics is utilised to attempt to either enhance performance or reduce the injury risk in the sport and exercise tasks examined.

Principles of Biomechanics

It is important to know several biomechanical terms and principles when examining the role of biomechanics in sport and exercise.

Forces and Torques

A force is simply a push or pull and it changes the motion of a body segment or the racket. Motion is created and modified by the actions of forces (mostly muscle forces, but also by external forces from the environment). When force rotates a body segment or the racquet, this effect is called a torque or moment of force. Example – Muscles create a torque to rotate the body segments in all tennis strokes. In the service action internal rotation of the upper arm, so important to the power of the serve, is the result of an internal rotation torque at the shoulder joint caused by muscle actions (latissimus dorsi and parts of the pectoralis major and deltoid). To rotate a segment with more power a player would generally apply more muscle force.

Newton’s Laws of Motion

Newton’s Three Laws of Motion explain how forces create motion in sport. These laws are usually referred to as the Laws of Inertia, Acceleration, and Reaction.

1. Law of Inertia – Newton’s First Law of inertia states that objects tend to resist changes in their state of motion. An object in motion will tend to stay in motion and an object at rest will tend to stay at rest unless acted upon by a force. Example – The body of a player quickly sprinting down the field will tend to want to retain that motion unless muscular forces can overcome this inertia or a skater gliding on ice will continue gliding with the same speed and in the same direction, barring the action of an external force.
2. Law of Acceleration – Newton’s Second Law precisely explains how much motion a force creates. The acceleration (tendency of an object to change speed or direction) an object experiences is proportional to the size of the force and inversely proportional to the object’s mass (F = ma). Example – When a ball is thrown, kicked, or struck with an implement, it tends to travel in the direction of the line of action of the applied force. Similarly, the greater the amount of force applied, the greater the speed the ball has. If a player improves leg strength through training while maintaining the same body mass, they will have an increased ability to accelerate the body using the legs, resulting in better agility and speed. This also relates to the ability to rotate segments, as mentioned above.
3. Law of Reaction – The Third Law states that for every action (force) there is an equal and opposite reaction force. This means that forces do not act alone, but occur in equal and opposite pairs between interacting bodies. Example – The force created by the legs “pushing” against the ground results in ground reaction forces in which the ground “pushes back” and allows the player to move across the court (As the Earth is much more massive than the player, the player accelerates and moves rapidly, while the Earth does not really accelerate or move at all). This action-reaction also occurs at impact with the ball as the force applied to the ball is matched with an equal and opposite force applied to the racket/body.

Momentum

Newton’ Second Law is also related to the variable momentum, which is the product of an object’s velocity and mass. Momentum is essentially the quantity of motion an object possesses. Momentum can be transferred from one object to another. There are different types of momentum which each have a different impact on the sport. 

Linear Momentum

Linear momentum is momentum in a straight line e.g. linear momentum is created as the athlete sprints in a straight line down the 100m straight on the track.

Angular Momentum

Angular momentum is rotational momentum and is created by the rotations of the various body segments e.g. The open stance forehand uses significant angular momentum. The tremendous increase in the use of angular momentum in ground strokes and serves has had a significant impact on the game of tennis. One of the main reasons for the increase in power of the game today is the incorporation of angular momentum into ground stroke and serve techniques. In tennis, the angular momentum developed by the coordinated action of body segments transfers to the linear momentum of the racquet at impact.

Centre of Gravity

The Center of Gravity (COG) is an imaginary point around which body weight is evenly distributed. The center of gravity of the human body can change considerably because the segments of the body can move their masses with joint rotations. This concept is critical to understanding balance and stability and how gravity affects sport techniques.

The direction of the force of gravity through the body is downward, towards the center of the earth and through the COG. This line of gravity is important to understand and visualise when determining a person’s ability to successfully maintain balance. When the line of gravity falls outside the Base of Support (BOS), then a reaction is needed in order to stay balanced.

The center of gravity of a squash racquet is a far simpler process and can usually be found by identifying the point where the racket balances on your finger or another narrow object.

Balance

Balance is the ability of a player to control their equilibrium or stability. You need to have a good understanding of both static and dynamic balance:

Static Balance

The ability to control the body while the body is stationary. It is the ability to maintain the body in some fixed posture. Static balance is the ability to maintain postural stability and orientation with center of mass over the base of support and body at rest.

Dynamic Balance 

The ability to control the body during motion. Defining dynamic postural stability is more challenging, Dynamic balance is the ability to transfer the vertical projection of the center of gravity around the supporting base of support. Dynamic balance is the ability to maintain postural stability and orientation with center of mass over the base of support while the body parts are in motion.

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Correct Biomechanics

As mentioned above, correct biomechanics provide efficient movement and may reduce the risk of injury. In sport, it is always good to consider abnormal or faulty biomechanics as a possible cause of injury. These abnormal biomechanics can be due to anatomical or functional abnormalities. Anatomical abnormalities such as leg length discrepancies cannot be changed, but the secondary effects can be addressed such as a shoe build up or orthotics for example. Functional abnormalities that can occur can be muscle imbalances after a long period of immobilisation.

Incorrect technique can cause abnormal biomechanics which can lead to injuries. Below are some examples of the relationship between faulty technique and associated injuries.

Sport	Technique	Injury
Cricket	Mixed bowling action	Pars interarticularis stress fractures
Tennis	Excessive wrist action with backhand	Extensor tendinopathy of the elbow
Swimming	Decreased external rotation of the shoulder	Rotator cuff tendinopathy
Running	Anterior pelvic tilt	Hamstring injuries
Rowing	Change from bow side to stroke side	Rib stress fractures
Ballet	Poor turnout	Hip Injuries

Lower Limb Biomechanics

As humans, ambulation is our main form of movement, that is we walk upright and are very reliant on our legs to move us about. How the foot strikes the ground and the knock on effect this has up the lower limbs to the knee, hips, pelvis and low back in particular has become a subject of much debate and controversy in recent years. 

Lower limb biomechanics refers to a complex interplay between the joints, muscles and nervous system which results in a certain patterning of movement, often referred to as ‘alignment’. Much of the debate centers around what is considered ‘normal’ and what is considered ‘abnormal’ in biomechanical terms as well as the extent to which we should intervene should abnormal findings be found on assessment. This section examines the biomechanics of the lower extremity in particular the anatomy and biomechanics of the foot and ankle, the impact of Q Angle on the mechanics of the hip and knee and finally the implications of this on gait.

Foot and Ankle Biomechanics

The foot and ankle form a complex system which consists of 26 bones, 33 joints and more than 100 muscles, tendons and ligaments. It functions as a rigid structure for weight bearing and it can also function as a flexible structure to conform to uneven terrain. The foot and ankle provide various important functions which include: supporting body weight, providing balance, shock absorption, transferring ground reaction forces, compensating for proximal malalignment, and substituting hand function in individuals with upper extremity amputation/paralysis all which are key when involved with any exercise or sport involving the lower limbs. This page examines in detail the biomechanics of the foot and ankle and its role in locomotion. 

Q Angle

An understanding of the normal anatomical and biomechanical features of the patellofemoral joint is essential to any evaluation of knee function. The Q angle formed by the vector for the combined pull of the quadriceps femoris muscle and the patellar tendon, is important because of the lateral pull it exerts on the patella.

The direction and magnitude of force produced by the quadriceps muscle have great influence on patellofemoral joint biomechanics. The line of force exerted by the quadriceps is lateral to the joint line mainly due to the large cross-sectional area and force potential of the vastus lateralis. Since there exists an association between patellofemoral pathology and excessive lateral tracking of the patella, assessing the overall lateral line of pull of the quadriceps relative to the patella is a meaningful clinical measure. Such a measure is referred to as the Quadriceps angle or Q angle. It was initially described by Brattstrom.

Biomechanics of Gait

Sandra J. Shultz describes gait as: “…someone’s manner of ambulation or locomotion, involves the total body. Gait speed determines the contribution of each body segment. Normal walking speed primarily involves the lower extremities, with the arms and trunk providing stability and balance. The faster the speed, the more the body depends on the upper extremities and trunk for propulsion as well as balance and stability. The legs continue to do the most work as the joints produce greater ranges of motion through greater muscle responses. In the bipedal system the three major joints of the lower body and pelvis work with each other as muscles and momentum move the body forward. The degree to which the body’s center of gravity moves during forward translation defines efficiency. The body’s center moves both side to side and up and down during gait.” Bipedal walking is an important characteristic of humans. This page will present information about the different phases of the gait cycle and important functions of the foot while walking. 

Upper Limb Biomechanics

Correct biomechanics are as important in upper limb activities as they are in lower limb activities. The capabilities of the upper extremity are varied and impressive. With the same basic anatomical structure of the arm, forearm, hand, and fingers, major league Baseball Pitchers pitch fastballs at 40 m/s, swimmers cross the English Channel, gymnasts perform the iron cross, and olympic boxers in weight classes ranging from flyweight to super heavyweight showed a range of 447 to 1,066 pounds of peak punching force.

The structure of the upper extremity is composed of the shoulder girdle and the upper limb. The shoulder girdle consists of the scapula and clavicle, and the upper limb is composed of the arm, forearm, wrist, hand, and fingers. However, a kinematic chain extends from the cervical and upper thoracic spine to the fingertips. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles.

This section reviews the anatomical structures enabling these different types of movement and examines the biomechanics or ways in which the muscles cooperate to achieve the diversity of movement of which the upper extremity is capable.

Scapulohumeral Rhythm

Scapulohumeral rhythm (also referred to as glenohumeral rhythm) is the kinematic interaction between the scapula and the humerus, first published by Codman in the 1930’s. This interaction is important for the optimal function of the shoulder. When there is a change of the normal position of the scapula relative to the humerus, this can cause a dysfunction of the scapulohumeral rhythm. The change of the normal position is also called scapular dyskinesia. Various studies of the mechanism of the shoulder joint that have attempted to describe the global motion capacity of the shoulder refer to that description, Can you evaluate the shoulder to see if the function is correct and explain the complex interactions between components involved in placing the hand in space?

Sport Specific Biomechanics

Running Biomechanics

Running is similar to walking in terms of locomotive activity. However, there are key differences. Having the ability to walk does not mean that the individual has the ability to run. There are some differences between the gait and run cycle – the gait cycle is one third longer in time, the ground reaction force is smaller in the gait cycle (so the load is lower), and the velocity is much higher. In running, there is also just one stance phase while in stepping there are two. Shock absorption is also much larger in comparison to walking. This explains why runners have more overload injuries.

Running Requires:

• Greater balance
• Greater muscle strength
• Greater joint range of movement 

Cycling Biomechanics

Cycling was initially invented by Baron Carl von Drais in 1817, but not as we know it. This was a machine which initially had two wheels that were connected by a wooden plank with a rudder device for steering. It involved people running along the ground whilst sitting down; giving them the name of a ‘running machine’ (in all senses) or a velocipede. This was solely used by the male population at the time of invention. The velocipede then made a huge design development in the 1860s at the Michaux factory in Paris. They added leaver arms to the front wheel which were propelled by pedals at the feet. This was the first conventional bicycle, and since then and up until the current day the bicycle has made great design and technological advances.
A survey in 2014 estimated that over 43% of the United Kingdom population have or have access to a bike and 8% of the population aged 5 and above cycled 3 or more times a week. With such a large amount of people cycling, whether it be professional, recreational or for commuting this increase the chance of developing an injury, so it is time we understood the biomechanics of cycling.

Baseball Pitching Biomechanics

Baseball pitching is one of the most intensely studying athletic motions. Although the focus has been more on the shoulder movement, entire body movement is required to perform baseball pitching. Throwing is also considered one of the fastest human motions performed, and maximum humeral internal rotation velocity reaches about 7000 to 7500o/second.

Tennis Biomechanics

Tennis biomechanics is a very complex task. Consider hitting a tennis ball. First, the athlete needs to see the ball coming off their opponent’s racket. Then, in order, they have to judge the speed, spin, trajectory and, most importantly, the direction of the tennis ball. The player then needs to adjust their body position quickly to move around the ball. As the player prepares to hit the ball the body is in motion, the ball is moving both in a linear and rotation direction if there is spin on the ball, and the racquet is also in motion. The player must coordinate all these movements in approximately a half a second so they strike the ball as close to the center of the racket in order to produce the desired spin, speed and direction for return of the ball. A mistake in any of these movements can create an error.

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Human beings are able to produce a variety of postures and movements giving them the ability to move from one place to another, i.e. the locomotive function. This is made possible by our musculoskeletal system that supports body loads and movement of body segments. This function is embedded in the principles of human biomechanics.

Biomechanics is considered to be one of the underpinning principles in physiotherapy practice to provide optimal care for movement-related injuries or conditions.

Image 1: Position of the centre of gravity “T” at different positions of the human body

Biomechanics major applications areas: improving movement performance; reduction of movement impairment; intervention in movement-related injuries or conditions.

Physiotherapists make use of biomechanical principles in eg

1. Therapeutic exercises: range of motion; active and passive insufficiency; concave-convex rule; Newton’s laws of motion.
2. Ergonomic training and the design of modern orthopaedic devices eg advanced walking aids are based on the application of the biomechanics concept.

How Do We Solve Problems in Biomechanics?

Knowing that biomechanical principles have a role in physiotherapy practice it is important to understand how to solve problems relating to biomechanics. Biomechanics provides information for a variety of kinesiology professions to analyze human movement to improve effectiveness or decrease the risk of injury. How the movement is analyzed falls on a continuum between a qualitative analysis and a quantitative analysis.

1. Quantitative analysis involves the measurement of biome-chanical variables and usually requires a computer to do the voluminous numerical calculations performed. Even short movements will have thousands of samples of data to be collected, scaled, and numerically processed.
2. Qualitative analysis has been defined as the “systematic observation and introspective judgment of the quality of human movement for the purpose of providing the most appropriate intervention to improve performance”. Knudson and Morrison.

Image 2: X-ray, orthopedic performance and biomechanics – Epiphysesis of the knee joints used to stop the growth by fixing the growth plate with metal clamps ( used to compensate for the unequal growth of the length of the limbs).

Basic Biomechanics Terminology

Mechanics is a branch of science that deals with forces and the effects produced by these forces.

The application of this science to the biological system is referred to as biomechanics.

• Human biomechanics focuses on how forces act on the musculoskeletal system and how the body tissue responds to these forces.
• Using the forces involved in the production of movement and posture, biomechanics can be viewed in the context of either external or internal biomechanics.

1. External biomechanics describes external forces on body segments and their effect on body movement,
2. Internal biomechanics are forces generated by the body tissues and their effect on movement.”This included the muscle forces and the forces in bones and joints that result from transmission of the muscle forces through the skeleton”.

External Forces (External Biomechanics)

Mechanics Domain

There are two domains of mechanics (biomechanics):

1. Static: describes mechanics that analyse the bodies at rest or in uniform motion
2. Dynamics: the study of conditions under which an object moves.

The dynamics concept can be further discussed under kinematics and kinetics.

• The kinetics concept: deals with body motion and the forces that cause it to move.Kinematics describes: body motion without regard to the forces that produce that motion.

Kinematics Variables

In kinematics, there are five variables of interest:

1. Type of motion or displacement,
2. The location,
3. The direction,
4. The magnitude
5. Rate of the motion or displacement.

1.Type of motion

Human motion is described as general motion (a complex combination of linear and angular components of motion). Most of the time human motion is analysed as either linear or angular motion as these two types of motion are basically considered “pure” motion.

• Linear motion (or translatory or translational motion): all parts of the body are moving in the same direction and at the same speed. If this motion occurs along a : straight line it is referred to as linear or rectilinear motion; a curved path it is referred to as curvilinear path.
• Angular motion is described as a rotation that occurs around a central imaginary line known as the rotation axis.

Pure linear movement in humans, like in walking, running and swimming rarely occur as the orientation of body segments to each other changes continually.

• In activities like skating and ski jumping there might be brief moments of pure linear motion.

The movement of a multi-segmented body, like the human body, which involves simultaneous linear and angular motion of the segments, is usually referred to as general motion. In humans, whole-body movements are described as general motion, as explained in the following examples

• When a person walks, the head and trunk movements are fairly linear, but the legs and arms movements are linear and angular simultaneously as the person’s body translates forward
• In cycling, the head, trunk and arms move in a fairly linear fashion but the legs move simultaneously in a linear and angular motion.

2. Magnitude of Motion

For angular motion, its magnitude can be measured and recorded in radians or degrees with the use of a goniometer. While the linear motion of a segment is measured by the linear distance that the object covered and this can be evaluated with walking assessment tools like 6-minute walk test.

3. Rate of Motion

Speed or velocity is used to measure the rate of motion and change in velocity is acceleration.

4. Location of Joint Motion in Space

One common reference system for location joint motion is that of anatomical planes and axes. A plane of motion can be described as a particular dimension of motion that runs through an imaginary flat surface of the body and an axis is an imaginary line that the body segment is rotating about. There are three planes of motion in the body, namely the sagittal, frontal and transverse planes.

• A sagittal plane has its axes as mediolateral, also known as transverse axes
• The frontal (coronal) and transverse planes have their axes as anteroposterior and longitudinal respectively.

5. Direction of Motion

The direction of motion can be described in terms of how the movement occurs along the plane and axis.

• When a motion reduces joint angle in the sagittal plane it is called flexion and a motion that increases the joint angle extension. Other common direction of motion in the sagittal plane are dorsiflexion and planter-flexion.
• Movement to the extremes of the range of motion are often referred to as “hyper,” as is the case with hyperextension, and this also occurs in the sagittal plane.
• The motion of a segment away from the midline in the frontal plane is called “abduction,” while the movement back toward the midline is called “adduction”. Other directions of motion that is common in this plane include eversion and inversion.
• Common motion along the transverse plane are internal rotation and external rotation, pronation and supination are also common motion along the transverse plane.

There are other directional terms to help describe the position of the body segment relative to the anatomical position eg

• Superior and inferior, which describes body position towards the head and the feet, respectively.
• Anterior and posterior can be used to describe objects related to the body as the front or back orientation to the body, respectively.
• Parts or movement towards the midline of the body is called medial, while motion or position towards the sides of the body is lateral.

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Kinematic Chain

The kinematic chain (also referred to as the kinetic chain in literature). Combinations of the degree of freedoms form kinematics chain – kinematics chain can be opened or closed.

1. In an open kinematic chain, the degree of freedom describes the number of directions that a joint allows a body segment to move and it is the number of independent coordinates that is used to precisely specify the position of the object in space.
2. Closed Kinetic Chain (CKC) exercises or closed chain exercises are exercises or movements where the distal aspect of the extremity is fixed to an object that is stationary.

Levangie and Norkin, elucidated that the open and closed park position concept help to describe movements that are taking place under weight-bearing and non-weight-bearing conditions and it is important to take note of these when exercise is to target single or multiple joints.

An order of natural kinetic chain in the upper and lower extremity involves an integrated biomechanical task that when impaired results in dysfunctional biomechanical output leading to pain and/or injury.

• Eg in the shoulder, when deficits exist in the preceding links, they can negatively affect the shoulder. Therefore, while managing shoulder dysfunction, an attempt should be made to restore all kinetic chain deficits and therapeutic sessions should follow integrated exercises on proprioception, flexibility, strength and endurance with kinetic chain order.

PRINCIPLES OF BIOMECHANICS

Acceleration. the rate at which speed changes.

• agonist. the muscle most directly involved in creating movement. …
• anatomical position. the body standing erect with arms down and palms forward.
• angle of pennation. …
• angular displacement. …
• angular velocity. …
• antagonist. …
• biomechanics.

Kinetic Concept in Motion Analysis

While kinematic concepts describe a segment of a body’s motion, the concept of kinetics gives us an idea of the forces associated with that movement. When discussing the kinetic concept of motion analysis we need to define force in biomechanics. Force is a simple way to represent load in biomechanics and can be defined as the action of one object to another. Force can be external or internal.

• External forces either pull or push on the body that occurs from sources outside the body
• Internal forces are those forces that act on the structures of the body and are generated by the body tissue.

Forces

• Cam change the shape and the state of motion of an object.
• Characterized by magnitude, direction and point of application.

All these factors determine the effect of force on an object. There are multiple forces that act on an object and it is possible to resolve these forces into a single ‘resultant’ force that has the same effect as all other forces acting together. The process of combining these two or more forces into a single resultant force is known as the composition of forces. Having understood what force is, it is essential to look into some of the laws guiding the force application.

Levangie and Norkin, reiterated that there are three primary rules of forces:

1. A force that acts on a segment must come from something
2. Anything that contacts a segment must create a force on that segment
3. Gravity is considered to have a force effect on all objects.

The principle of understanding the biomechanics of movement is an in-depth understanding of force, Newton’s laws of motion, work and energy

FORCES AND TORQUES  :

A force is simply a push or pull and it changes the motion of a body segment or the racket. Motion is created and modified by the actions of forces (mostly muscle forces, but also by external forces from the environment). When force rotates a body segment or the racquet, this effect is called a torque or moment of force

NEWTON’S LAW  :

1) Law of Inertia –

Newton’s First Law of inertia states that objects tend to resist changes in their state of motion. An object in motion will tend to stay in motion and an object at rest will tend to stay at rest unless acted upon by a force.

2) Law of Acceleration

Newton’s Second Law precisely explains how much motion a force creates. The acceleration (tendency of an object to change speed or direction) an object experiences is proportional to the size of the force and inversely proportional to the object’s mass.

3) Law of Reaction

– The Third Law states that for every action (force) there is an equal and opposite reaction force. This means that forces do not act alone, but occur in equal and opposite pairs between interacting bodies.

TYPE OF MOMENTUM

1) LINEAR MOMENTUM

Linear momentum is momentum in a straight line e.g. linear momentum is created as the athlete sprints in a straight line down the 100m straight on the track.

2) ANGULAR MOMENTUM

Angular momentum is rotational momentum and is created by the rotations of the various body segments e.g. The open stance forehand uses significant angular momentum. The tremendous increase in the use of angular momentum in ground strokes and serves has had a significant impact on the game of tennis. One of the main reasons for the increase in power of the game today is the incorporation of angular momentum into ground stroke and serve techniques. In tennis, the angular momentum developed by the coordinated action of body segments transfers to the linear momentum of the racquet at impact.

*CENTER OF GRAVITY

Center of Gravity (COG) is an imaginary point around which body weight is evenly distributed. The center of gravity of the human body can change considerably because the segments of the body can move their masses with joint rotation

*BALANCE
Balance is the ability of a player to control their equilibrium or stability.

1) STATIC BALANCE

The ability to control the body while the body is stationary. It is the ability to maintain the body in some fixed posture[12]. Static balance is the ability to maintain postural stability and orientation with center of mass over the base of support and body at rest

2) DYNAMIC BALANCE

The ability to control the body during motion. Defining dynamic postural stability is more challenging, Dynamic balance is the ability to transfer the vertical projection of the center of gravity around the supporting base of support.Dynamic balance is the ability to maintain postural stability and orientation with center of mass over the base of support while the body parts are in motion.

IMPORTANCE OF BIO-MECHANICS

In sport and exercise, bio-mechanics refers to the study of human movements, including the interaction between the athlete, sport equipment and the exercise environment. Athletes are always trying to find ways to get faster, higher and stronger with minimal injury

Q ANGLE :
An understanding of the normal anatomical and bio-mechanical features of the patello-femoral joint is essential to any evaluation of knee function. The Q angle formed by the vector for the combined pull of the quadriceps femoris muscle and the patellar tendon, is important because of the lateral pull it exerts on the patella.

The direction and magnitude of force produced by the quadriceps muscle has great influence on patellofemoral joint biomechanics. The line of force exerted by the quadriceps is lateral to the joint line mainly due to large cross-sectional area and force potential of the vastus lateralis. Since there exists an association between patellofemoral pathology and excessive lateral tracking of the patella, assessing the overall lateral line of pull of the quadriceps relative to the patella is a meaningful clinical measure. Such a measure is referred to as the Quadriceps angle or Q angle. It was initially described by Breaststroke

USE OF BIOMECHANICS FOR SPORTS AND EXERCISE
Sports biomechanics studies human motion during exercise and in sports. Physics and the laws of mechanics are applied to athletic performance. Biomechanics can be applied to individuals, analyzing their movements and coaching them for more effective movement during exercise and sports movement.

INJURIES DUE TO INCORRECT BIO-MECHANICS :

Sport	Technique	Injury
Cricket	Mixed bowling action	Pars inter_ articularis stress fractures
Tennis	Excessive wrist action with backhand	Extensor tendinopathy of the elbow
Swimming	Decreased external rotation of the shoulder	Rotator cuff tendino pathy
Running	Anterior pelvic tilt	Hamstring injuries
Rowing	Change from bow side to Change from bow side to	rib stress fracture
Ballet	Poor turnout	Hip Injuries

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Your skin has tiny holes called pores that can become blocked by oil, bacteria, dead skin cells, and dirt. When this occurs, you may develop a pimple or “zit.” If your skin is repeatedly affected by this condition, you may have acne.

According to the American Academy of Dermatology, acne is the most common skin condition in the U.S. Although acne isn’t a life-threatening condition, it can be painful, particularly when it’s severe. It can also cause emotional distress.

Acne that appears on your face can affect your self-esteem and, over time, may cause permanent physical scarring.

There are many effective treatments for acne that reduce both the number of pimples you get and your chance of scarring.

Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells. It causes whiteheads, blackheads or pimples. Acne is most common among teenagers, though it affects people of all ages.

Effective acne treatments are available, but acne can be persistent. The pimples and bumps heal slowly, and when one begins to go away, others seem to crop up.

Depending on its severity, acne can cause emotional distress and scar the skin. The earlier you start treatment, the lower your risk of such problems.

Causes

Four main factors cause acne:

• Excess oil (sebum) production
• Hair follicles clogged by oil and dead skin cells
• Bacteria
• Inflammation

Acne typically appears on your face, forehead, chest, upper back and shoulders because these areas of skin have the most oil (sebaceous) glands. Hair follicles are connected to oil glands.

The follicle wall may bulge and produce a whitehead. Or the plug may be open to the surface and darken, causing a blackhead. A blackhead may look like dirt stuck in pores. But actually the pore is congested with bacteria and oil, which turns brown when it’s exposed to the air.

Pimples are raised red spots with a white center that develop when blocked hair follicles become inflamed or infected with bacteria. Blockages and inflammation deep inside hair follicles produce cystlike lumps beneath the surface of your skin. Other pores in your skin, which are the openings of the sweat glands, aren’t usually involved in acne.

Certain things may trigger or worsen acne:

• Hormonal changes. Androgens are hormones that increase in boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormone changes during midlife, particularly in women, can lead to breakouts too.
• Certain medications. Examples include drugs containing corticosteroids, testosterone or lithium.
• Diet. Studies indicate that consuming certain foods — including carbohydrate-rich foods, such as bread, bagels and chips — may worsen acne. Further study is needed to examine whether people with acne would benefit from following specific dietary restrictions.
• Stress. Stress doesn’t cause acne, but if you have acne already, stress may make it worse.

Acne myths

These factors have little effect on acne:

• Chocolate and greasy foods. Eating chocolate or greasy food has little to no effect on acne.
• Hygiene. Acne isn’t caused by dirty skin. In fact, scrubbing the skin too hard or cleansing with harsh soaps or chemicals irritates the skin and can make acne worse.
• Cosmetics. Cosmetics don’t necessarily worsen acne, especially if you use oil-free makeup that doesn’t clog pores (noncomedogenics) and remove makeup regularly. Nonoily cosmetics don’t interfere with the effectiveness of acne drugs.

Symptoms

Acne signs vary depending on the severity of your condition:

• Whiteheads (closed plugged pores)
• Blackheads (open plugged pores)
• Small red, tender bumps (papules)
• Pimples (pustules), which are papules with pus at their tips
• Large, solid, painful lumps under the skin (nodules)
• Painful, pus-filled lumps under the skin (cystic lesions)

Acne usually appears on the face, forehead, chest, upper back and shoulders.

When to see a doctor

If self-care remedies don’t clear your acne, see your primary care doctor. He or she can prescribe stronger medications. If acne persists or is severe, you may want to seek medical treatment from a doctor who specializes in the skin (dermatologist or pediatric dermatologist).

For many women, acne can persist for decades, with flares common a week before menstruation. This type of acne tends to clear up without treatment in women who use contraceptives.

In older adults, a sudden onset of severe acne may signal an underlying disease requiring medical attention.

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The Food and Drug Administration (FDA) warns that some popular nonprescription acne lotions, cleansers and other skin products can cause a serious reaction. This type of reaction is quite rare, so don’t confuse it with any redness, irritation or itchiness that occurs in areas where you’ve applied medications or products.

Seek emergency medical help if after using a skin product you experience:

• Faintness
• Difficulty breathing
• Swelling of the eyes, face, lips or tongue
• Tightness of the throat

Complications

People with darker skin types are more likely than are people with lighter skin to experience these acne complications:

• Scars. Pitted skin (acne scars) and thick scars (keloids) can remain long-term after acne has healed.
• Skin changes. After acne has cleared, the affected skin may be darker (hyperpigmented) or lighter (hypopigmented) than before the condition occurred.

Risk factors

Risk factors for acne include:

• Age. People of all ages can get acne, but it’s most common in teenagers.
• Hormonal changes. Such changes are common during puberty or pregnancy.
• Family history. Genetics plays a role in acne. If both of your parents had acne, you’re likely to develop it too.
• Greasy or oily substances. You may develop acne where your skin comes into contact with oil or oily lotions and creams.
• Friction or pressure on your skin. This can be caused by items such as telephones, cellphones, helmets, tight collars and backpacks.

How is acne diagnosed?

If you have symptoms of acne, your doctor can make a diagnosis by examining your skin. Your doctor will identify the types of lesions and their severity to determine the best treatment.

How is acne treated?

At-home care

There are a few self-care activities you can try at home to prevent pimples and clear up your acne. Home remedies for acne include:

• cleaning your skin daily with a mild soap to remove excess oil and dirt
• shampooing your hair regularly and keeping it out of your face
• using makeup that’s water-based or labeled “noncomedogenic” (not pore-clogging)
• not squeezing or picking pimples, which spreads bacteria and excess oil
• not wearing hats or tight headbands
• not touching your face

Medication

If self-care doesn’t help with your acne, a few over-the-counter acne medications are available. Most of these medications contain ingredients that can help kill bacteria or reduce oil on your skin. These include:

• Benzoyl peroxide is present in many acne creams and gels. It’s used for drying out existing pimples and preventing new ones. Benzoyl peroxide also kills acne-causing bacteria.
• Sulfur is a natural ingredient with a distinctive smell that’s found in some lotions, cleansers, and masks.
• Resorcinol is a less common ingredient used to remove dead skin cells.
• Salicylic acid is often used in soaps and acne washes. It helps prevent pores from getting plugged.

Sometimes, you may continue to experience symptoms. If this happens, you may want to seek medical advice. Your doctor can prescribe medications that may help reduce your symptoms and prevent scarring. These include:

• Oral or topical antibiotics reduce inflammation and kill the bacteria that cause pimples. Typically, antibiotics are only used for a short time so that your body doesn’t build up a resistance and leave you prone to infections.
• Prescription topical creams such as retinoic acid or prescription-strength benzoyl peroxide is often stronger than over-the-counter treatments. They work to reduce oil production. Benzoyl peroxide serves as a bactericidal agent that prevents the resistance of acne-causing bacteria to antibiotics. It also has moderate comedone-destroying and anti-inflammatory properties.

Women with hormonal acne may be treated with birth control pills or spironolactone. These medications regulate hormones that can cause acne through a decrease in oil production.

Isotretinoin (Accutane) is a vitamin-A-based medication used to treat certain cases of severe nodular acne. It can cause serious side effects, and it’s only used when other treatments don’t work.

Your doctor may recommend procedures to treat severe acne and prevent scarring. These procedures work by removing damaged skin and reducing oil production. They include:

• Photodynamic therapy uses medication and a special light or laser to reduce oil production and bacteria. Other lasers may be used alone to help improve acne or scarring.
• Dermabrasion removes the top layers of your skin with a rotating brush and would be best for treating acne scarring as opposed to a treatment for acne. Microdermabrasion is a milder treatment that helps remove dead skin cells.
• A chemical peel removes the top layers of your skin. That skin peels off to reveal less damaged skin underneath. Chemical peels can improve mild acne scarring.
• Your doctor may suggest using cortisone injections if your acne consists of large cysts. Cortisone is a steroid naturally produced by your body. It can reduce inflammation and speed healing. Cortisone is usually used along with other acne treatments.

What is the outlook for someone with acne?

Treatment for acne is often successful. Most people can expect their acne to begin clearing up within six to eight weeks. However, flare-ups are common and may require additional or long-term treatment. Isotretinoin is the treatment most likely to provide permanent or long-term positive results.

Acne scarring can cause emotional distress. But, prompt treatment can help prevent scarring. Also, your dermatologist will have treatment options designed to treat scarring.

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Penis health is an important part of your health — and it goes beyond your ability to get and keep an erection, ejaculate, and reproduce.

Penis problems can be a sign of an underlying health condition. Ongoing health issues affecting your penis also can impact other areas of your life, causing stress, relationship problems or poor self-confidence. Know the signs and symptoms of penis problems and what you can do to protect your penis health.

What conditions affect penis health and function?

Problems related to sexual function, sexuality activity and penis health include:

• Erectile dysfunction, the inability to get and keep an erection firm enough for sex
• Ejaculation problems, including the inability to ejaculate, premature ejaculation, delayed ejaculation, painful ejaculation, reduced ejaculation or retrograde ejaculation, when semen enters the bladder instead of emerging through the penis
• Anorgasmia, the inability to achieve an orgasm despite adequate stimulation
• Decreased libido, a reduced desire for sex
• Sexually transmitted infections — including genital warts, gonorrhea, chlamydia, syphilis and genital herpes — that can cause painful urination, penis discharge, and sores or blisters on the penis or in the genital area
• Yeast infection, which can cause inflammation of the head of the penis (balanitis), a reddish rash, white patches on the penis, itching or burning, and a white discharge
• Peyronie’s disease, a chronic condition that involves the development of abnormal scar tissue inside the penis, often resulting in bent or painful erections
• Penile fracture, rupture during an erection of the fibrous, tubelike tissue in the penis, usually caused by an erect penis forcefully striking the female pelvis during sex
• Priapism, a persistent and usually painful erection that isn’t caused by sexual stimulation or arousal
• Phimosis, a condition in which the foreskin of an uncircumcised penis can’t be retracted from the penis head, causing painful urination and erections
• Paraphimosis, a condition in which the foreskin can’t be returned to its normal position after being retracted, causing painful swelling of the penis and impaired blood flow
• Penile cancer, which may begin as a blister on the foreskin, head or shaft of the penis and then become a wartlike growth that discharges watery pus

What factors increase the risk of problems?

Various risk factors can affect penis health — some modifiable and some not. For example:

• Heart disease, diabetes and related conditions. Heart disease, diabetes, high blood pressure, high cholesterol and obesity can increase the risk of erectile dysfunction.
• Certain medications. Erectile dysfunction is a possible side effect of a number of common medications, including blood pressure drugs, antidepressants, prescription sleep medicine, ulcer drugs and drugs for prostate cancer.
• Prostate cancer treatment. Surgical removal of the prostate gland (radical prostatectomy) and surrounding tissue as treatment for prostate cancer might cause urinary incontinence and erectile dysfunction.
• Smoking. Along with other health risks, smoking increases your chances of having erectile dysfunction.
• Excessive drinking. Excessive drinking can contribute to reduced libido, erectile dysfunction and poor choices in sexual behaviors.
• Hormone levels. Hormone imbalances, especially testosterone deficiency, have been linked to erectile dysfunction.
• Psychological factors. Depression, severe stress or other mental health impairments, as well as medications for these conditions, may increase the risk of erectile dysfunction. In turn, erectile dysfunction may contribute to anxiety, depression, low self-esteem or stress about sexual performance.
• Neurological conditions. Stroke, spinal cord and back injuries, multiple sclerosis, and dementia can affect the transfer of nerve impulses from the brain to the penis, causing erectile dysfunction.
• Getting older. Aging generally results in a decline in testosterone levels and is associated with an increased risk of erectile dysfunction, decreased intensity of orgasms, decreased force of ejaculation and less penile sensitivity to touch.
• Unsafe sex. Unprotected sex, sex with multiple partners and other risky sexual behaviors increase the risk of sexually transmitted infections.
• Piercings. A penis piercing can cause a skin infection and disrupt urinary flow. Depending where the piercing is placed, it might also worsen your ability to achieve an erection or orgasm.

When to see your doctor?

Consult your doctor as soon as possible if you have any of the following signs or symptoms:

• Changes in the way you ejaculate
• Abrupt changes in sexual desire
• Bleeding during urination or ejaculation
• Warts, bumps, lesions or a rash on your penis or in your genital area
• A severely bent penis or curvature that causes pain or interferes with sexual activity
• A burning sensation when you urinate
• Discharge from your penis
• Severe pain after trauma to your penis

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What can I do to keep my penis healthy?

You can take steps to protect your penis health and overall health. For example:

• Be sexually responsible. Use condoms or maintain a mutually monogamous relationship with a partner who’s been tested and is free of sexually transmitted infections.
• Get vaccinated. If you’re age 26 or younger, consider the human papillomavirus (HPV) vaccine to help prevent cancers associated with the virus.
• Stay physically active. Moderate physical activity can significantly reduce your risk of erectile dysfunction.
• Make healthy choices. Maintaining a healthy weight can help reduce the risk of developing high cholesterol, high blood pressure, type 2 diabetes and other risk factors for erectile dysfunction.
• Practice good hygiene. If you’re not circumcised, regularly clean beneath your foreskin with soap and water. Be sure to return your foreskin to its normal position after sex.
• Know your medications. Discuss medication use and possible side effects with your doctor.
• Pay attention to your mental health. Seek treatment for depression, anxiety or other mental health conditions.
• Stop smoking and limit the amount of alcohol you drink. If you smoke, quit. If you need help quitting, talk to your doctor. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger.

Not all penis problems can be prevented. However, routinely examining your penis can give you greater awareness of the condition of your penis and help you detect changes. Regular checkups also can help ensure that problems affecting your penis are diagnosed as soon as possible.

While you might find it difficult to discuss problems affecting your penis with your doctor, don’t let embarrassment prevent you from taking charge of your health.

General tips

Penis health needs a holistic approach. In other words, taking care of all aspects of your general health is important for the health of your penis. This is especially important since a range of different health conditions can affect your fertility and penile health.

Stay hydrated

Hydration is important for your overall health, as well as the health of your penis. There might be a link between dehydration and ED, so try to get about two liters of water a day.

Eat a balanced diet

A balanced diet is key in helping you reduce your chances of developing diabetes and heart disease, both of which can cause ED.

One 2016 studyconducted among 25,096 subjects looked at the relationship between ED and flavonoids, which are mostly found in vegetables and fruit.

Researchers found that the subjects who regularly consumed flavonoids were less likely to develop ED.

Certain foods may also boost your testosterone levels and improve your fertility. This includes:

• spinach
• spicy foods with capsaicin
• avocado

Get regular exercise

Moderate physical activity can reduce your chances of ED.

One 2015 study looked at people with ED and a recent myocardial infarction, commonly referred to as a heart attack. It found that a home-based walking program can reduce ED.

Try exercising at least a few times a week — even a brisk walk every so often can improve your penile health.

Practice pelvic floor exercises

Pelvic floor exercises are often associated with vaginal health, but they can be helpful for everyone.

These exercises can improve your ability to get and maintain an erection, as well as prevent dribble after urination.

A small 2005 study on 55 people with ED found that pelvic exercises helped 40 percent of participants regain normal erectile function.

An additional 35.5 percent reported that, although they hadn’t completely regained normal function, their overall erectile function did improve.

You can do basic Kegel exercises by squeezing the muscles you use to urinate. Squeeze for five seconds, relax, and repeat for 10 rounds. Eventually, work your way up to 20 reps. Do this two or three times per day.

Maintain a healthy weight

Maintaining a healthy weight can reduce your chances of diabetes, high cholesterol, and heart disease, all of which affect your penile health.

Practice stress management

Practicing stress management is great for your overall health and the health of your penis.

Stress and anxiety can affect your sexual performance and fertility. Stress also increases your chances of developing cardiovascular disease, which can lead to ED.

Stress management techniques include:

• deep breathing
• spending time with loved ones
• journaling
• meditation

Practice sleep hygiene

Sleep is important for your vascular health, which affects your ability to become erect.

There seems to be a link between obstructive sleep apnea and ED, possibly because sleep deprivation can lead to low testosterone and other hormonal imbalances.

Avoid tobacco

Smoking cigarettes is strongly associated with ED.

A 2013 study showed that this possibly is because smoking disrupts your heart’s autonomic function, which in turn leads to ED.

Smoking can also decrease your fertility.

Drink alcohol in moderation, if at all

As with tobacco, excessive drinking can cause a number of health problems, which can in turn affect your penis health.

To help you manage your health, we’ll send you sharp coverage of fitness, nutrition, and other wellness topics just for men.

How to wash your penis

You can wash your pubic area using warm water and unscented, mild soap. Don’t use harsh soaps or scrub the area too hard, as the sensitive skin in the area can be irritated.

Make sure you:

1. Wash your pubic mound and the skin around the base of the penis, as well as the skin between your thighs and your pubic mound. Sweat can collect here.
2. Wash the shaft of your penis.
3. If you have a foreskin, gently pull it back and wash it. This helps to prevent smegma build-up, which can lead to conditions like balanitis.
4. Wash your scrotum and the skin around it.
5. Wash your perineum (the piece of skin between your scrotum and anus).
6. Wash near your anus and between your butt cheeks.

It’s best to wash your penis every time you bathe.

As you wash yourself, examine the skin around your groin for STI symptoms. This includes:

• unusual discharge
• rashes
• blisters
• warts

How to groom your pubic hair

Some people like grooming their pubic hair, while others don’t. Whether you groom your pubic hair or not is your decision.

If you’d like to remove or trim your pubic hair, keep your skin type in mind. This will help you avoid razor burn and other discomfort.

Shaving

Shaving is a painless way to remove hair. It’s important to take certain precautions to avoid getting a rash.

Shave in the same direction that your hair grows. Use shaving cream while shaving and apply cortisone cream after to reduce irritation.

Never share razors with anybody else, and disinfect yours before use. If you use disposable razors, replace them every so often.

Waxing or threading

Waxing involves applying warm wax to the skin and pulling the hair out from their follicles.

Threading involves twisting thread around the hairs and pulling them out by the root.

Waxing and threading can be uncomfortable — it all depends on your individual pain tolerance.

If done incorrectly, these removal methods can cause swelling and rash.

You can reduce your risk for discomfort by visiting a professional waxer or threader.

Chemical hair removal

Hair removal cream breaks down the proteins in hair so that it can be washed away and removed.

While it can be an effective way to remove hair, some people find that hair removal creams irritate their skin.

You shouldn’t use these creams if you have sensitive skin or chemical allergies.

If you do use hair removal cream, don’t apply it directly to your penis.

Trimming

If you don’t want to remove the hair entirely, you can trim it with a pair of scissors or electric trimmer.

Be sure to disinfect scissors before and after use. You should only use these scissors for grooming — using them for other tasks can spread germs.

How to prevent STIs

There are a number of ways to prevent STIs.

Get vaccinated

The Centers for Disease Control and Prevention (CDC)Trusted Source recommend that everyone gets vaccinated for human papillomavirus (HPV) around age 11 or 12.

Doing so at a young age — before you’re sexually active — ensures that you’re protected against HPV before you’re exposed to the virus.

But if you weren’t vaccinated as a child, you may still benefit from getting vaccinated as an adult. Talk to a doctor or other healthcare provider to learn more.

Get tested after every new partner

Many STIs are asymptomatic, which means that you won’t have any noticeable symptoms.

For this reason, it’s important to get tested before having sex with a new partner. Both you and your partners should get tested.

If you or a partner has an infection, you might be able to take certain precautions to prevent it from spreading between you.

For example, if you have HIV, your partner can take Truvada (pre-exposure prophylaxis, also known as PrEP) to help prevent them from contracting it.

Use a condom every time you have sex

Using a condom every time you have sex — oral, vaginal, or anal — is the best way to help prevent the spread of certain STIs.

If you don’t want to use a condom, ensure that both you and your partners don’t have any STIs.

If you suspect you’ve contracted an STI, try not to panic. Most are treatable, and it’s nothing to be ashamed of. Talk to a healthcare provider. They’ll help you find the cause of your symptoms and advise you on any next steps.

Common questions

At this point, you might have more questions about penis health. Here are some common concerns that many people have.

Does it matter if you’re circumcised?

Circumcision has its pros and cons. Whether you’re circumcised or not, it’s important to wash regularly.

If you have a foreskin, pull it back gently and clean it to avoid a smegma build-up. Circumcised penises are more likely to get chafed or irritated, so use loose-fitting, cotton underwear always.

Circumcision doesn’t affect fertility, but uncircumcised penises are more susceptible to STIs, as well as conditions like balanitis.

Practicing good hygiene and safe sex can reduce your chances of getting these conditions.

Does it matter if you’re a “grower” or a “shower”?

So far, there isn’t any scientific information that shows whether being a “grower” or a “shower” is better or healthier. Both are totally okay — so embrace whatever category your penis may fall into!

Is it normal for your penis to have a bend or a curve?

It’s normal for your penis to curve slightly, but if you have a significant bend and pain in your penis when it’s erect, you could have Peyronie’s disease.

This condition can cause some discomfort. It’s often caused by a traumatic injury.

If you’re concerned that you may have Peyronie’s, see a doctor or other healthcare provider.

Is “use it or lose it” true?

Many people believe that sex is a “use it or lose it” thing — that if you stop having sex, you’ll end up struggling to have sex.

While it’s true that frequent sex has many health benefits and can boost your sex drive, there’s no evidence that chastity can permanently or seriously damage your penis.

Is there such a thing as too much or too little ejaculate?

If you’re noticing that you are ejaculating a lower volume of semen than usual, it’s called perceived ejaculate volume reduction (PEVR).

This could be caused by a number of things, including depression, diabetes, and certain testicular conditions. It could also be a side effect of medication.

How can you maintain penis sensitivity as you age?

The tissue on your penis might lose sensitivity as you age. This could be caused by friction, so wear loose cotton underwear instead of tight, rough underwear.

How can you maintain your ability to get an erection?

Taking steps to reduce your risk of heart disease and diabetes — both of which can cause ED — can help you maintain your ability to get an erection.

What can you do to promote fertility?

Certain foods can promote fertility. For example, spinach contains magnesium, which can boost your testosterone levels.

Tomatoes and carrots can increase your sperm count and motility.

Other than that, healthy lifestyle choices help maintain fertility.

As outlined above, avoiding tobacco smoking and alcohol, eating a balanced diet, and exercising are all important for penis health.

Is it OK if your pee changes colors?

Your urine could change colors depending on how hydrated you are:

• Clear urine could mean you’re overhydrated.
• Yellow to amber urine is considered normal.
• Orange or brown urine could mean you’re dehydrated.

Some colors might also be a cause for concern.

For example, bloody, cloudy, blue, or green urine could indicate that you have an infection or another health condition.

See a doctor if you’re experiencing unusual changes in color or consistency.

What if you start peeing more than usual?

Frequent urination could be a sign of:

• urinary tract infection (UTI)
• diabetes
• interstitial cystitis

If you’re peeing a lot more than usual and you think something is wrong, contact a doctor. This is especially important if you’re experiencing a burning sensation during urination.

Is it normal for your penis to smell?

Your groin might naturally smell a little like sweat, as it’s common to sweat in that area. This smell can be reduced through daily washing.

However, the smell shouldn’t be pungent. An unpleasant-smelling penis could indicate that you have a condition such as:

• UTI
• yeast infection
• balanitis
• gonorrhea
• chlamydia

If the smell doesn’t clear with careful washing, see a doctor for diagnosis.

What if your penis is sore or inflamed?

If your penis is sore or inflamed, it could be a sign of certain penis conditions. This includes:

• balanitis
• phimosis, a condition where the foreskin can’t be pulled back over the head of the penis
• penile cancer, which is rare but serious

No matter the cause, pain and inflammation can be uncomfortable, so see a healthcare provider. They can help you find relief.

Is it possible to break or fracture you penis?

Although the penis doesn’t have bones in it, the term “penis fracture” is often used to refer to a penis injury where the lining inside becomes torn. This is often caused by rough sex.

If you fracture your penis, it will turn black and blue, flatten, and it may make a popping noise. This is considered a medical emergency and requires immediate attention.

When to see a doctor or other healthcare provider

Ideally, you should see a doctor once a year for a penile check-up.

Otherwise, you should seek medical attention if you experience:

• bruises on the penis
• yellow, green, or otherwise unusual penile discharge
• swelling or inflammation of the penis
• blisters, rashes, warts, or sores on or near your penis
• burning, pain, or bleeding when you urinate or ejaculate
• pain during sex
• pain during an erection
• difficulty getting or maintaining an erection

Check your groin for signs of infections and other conditions regularly.

If you have any concerns, don’t hesitate to speak to a healthcare provider. They can help set your mind at ease and advise you on any next steps.

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