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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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The phrase “feminine hygiene” belongs in the trash alongside your last soiled dental dam or tampon.

But that doesn’t mean vagina owners shouldn’t prioritize the health of their genitals — they should!

Read on to learn why the language used to describe vulvar health is garbage. Plus, what vulvar health and hygiene really entails.

What does ‘feminine hygiene’ actually mean?

As it’s primarily used, “feminine hygiene” doesn’t really mean anything.

It’s nothing more than a marketing ploy. One that’s based in transphobic, misogynistic values designed to make cisgender women feel ashamed of their genitals, and therefore buy so-called feminine hygiene products.

The (false) message: Using these products makes you (and your genitals) clean, while not using them makes you dirty.

Why is it referred to as ‘feminine’ and not ‘vulvar’?

“While the phrase ‘feminine hygiene’ is often used to make people with vaginas feel dirty, the goal of the phrase is recognizing the unique qualities of the parts that make up the vulva and the vaginal canal,” explains Felice Gersh, MD, author of “PCOS SOS: A Gynecologist’s Lifeline to Naturally Restore Your Rhythms, Hormones, and Happiness.”

So, actually, a better, more accurate phrase would be vulvar/vaginal hygiene.

If you’re wondering why the phrase “vulvar hygiene” would *not* suffice, here’s a quick anatomy lesson:

• The vagina = the internal part of the genitals. It’s the canal where things like tampons and dildos can go.
• The vulva = the external parts of the genitals, which include the pubic mount, inner and outer labia, clitoris, and the vestibule.

And as Gersh notes, here we want to be talking about both parts.

At what age should you start developing your routine? 

As young as possible, actually.

“Just as parents explain to their children that they need to clean between their toes and brush their teeth, they need to explain to their child that they should tend to their genitals,” Gersh says.

What does a typical routine consist of?

Just as oral hygiene entails more than just one thing, vulvar/vaginal hygiene does too!

Feeding

It really does all start with food!

“Our entire body needs a wide range of nutrients in order to function optimally,” Gersh says. “So, what we eat and drink affects our vulva and vagina in the same way that what we eat and drink affect all parts of our body.”

To maintain the most optimal vulvar and vaginal health, she recommends a diet rich in:

• antioxidants
• vitamin E
• vitamin C
• omega-3 fatty acids
• omega-6 fatty acids
• protein
• probiotics

Cleaning

Likely, cleaning your bits is a far less ~involved~ process than you might have guessed.

In the shower

The vagina is a self-cleaning machine.

If you’ve ever seen discharge in your undies — assuming it doesn’t have a new odor or tinge — that’s evidence that your vagina is functioning just right.

The vulva, on the other hand, isn’t self-cleaning.

“The vulva is skin, and it’s skin that needs to be washed just like any other skin on the body,” explains Lauren F. Streicher, MD, clinical professor of obstetrics and gynecology and author of “Sex Rx: Hormones, Health, and Your Best Sex Ever.”

“A mild, fragrance-free soap with water and your fingers in the shower are more than adequate enough,” she says.

After going to the bathroom

“The most important thing to keep in mind when wiping [after pooping and peeing] is that you want to wipe your anus and vagina separately,” Streicher says.

Meaning, wipe one area, discard the used paper. Then wipe the other area.

The reason? “You don’t want to contaminate the urethra with anything from the rectum, because it increases the risk of a urinary tract infection,” she says.

And if you wipe each area separately, that’s a nonissue.

Just peeing? Be sure to wipe front to back, always.

After sex

Simple: pee!

Peeing cleans out any bacteria that may have migrated into the urethra during play, which may help reduce the risk of a UTI, explains Gersh.

“You can also do one little swish of water on your vulva with your finger, but don’t do any internal washing or scrubbing,” she says.

Grooming

Pubic hair has many important biological purposes, says Streicher.

This includes protecting the delicate vulvar skin from friction during intercourse and other activities.

“But there has been no research that shows that the pubic hair has any function as far as hygiene goes,” she says.

That said, if you choose to remove some or all of your pubic hair, the way you do it matters.

“You want to use a fresh blade every time,” Streicher says. If that sounds too pricey, at the very least designate a vulva-only blade. That way you’re not using a blade that’s been dulled by shaving shag elsewhere on your body.

When you’re done, dry the razor and store it away in your cabinet as opposed to on a shower ledge. This can help keep the razor from growing mold and rust.

Even if you follow all these above steps perfectly, ingrown hair and irritation are still a risk. And for folks with uber-sensitive skin, they’re practically inevitable.

“A warm compress on the ingrown hair can help open the pore and pull the follicle from underneath the skin,” Streicher says.

But if the bump you think is an ingrown hair is accompanied by symptoms like funky discharge, a foul odor, or pain, reach out to a healthcare provider.

“They’ll be able to tell you if it’s actually an ingrown, and do any culture swaps they seem fit,” she says.

Soothing

“You really don’t need to be worrying about soothing your vulva skin unless it’s irritated,” Streicher says.

If it is irritated, she recommends backing off any fragrant products and switching to a soap bar with mild, hydrating aloe vera.

If the irritation doesn’t go away, reach out to a healthcare provider.

Monitoring

“The best way to tell if something is awry with your vagina and vulva is to become familiar with it,” says Aleece Fosnight, a board certified physician assistant and medical adviser at Aeroflow Urology.

Her suggestion? Spend time learning the way your genitals typically:

• look
• smell
• feel

How? By slowing down in the shower, sniffing the crotch of your panties, looking at your genitals with a hand mirror, touching or fingering yourself, and regularly going to the doctor.

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Should your routine change over time?

“The biggest indication that something needs to change is if you’re experiencing unpleasant side effects or pain,” Streicher says.

That said, there are some ~major life events~ that may necessitate an update to your routine. Including:

If you have (or continue to have!) sex

If you become a sexually active person, prioritizing your genital health means knowing your current STI status.

Sex isn’t just penis-in-vagina penetrative intercourse. It’s also:

• oral sex
• hand play
• bumping and grinding
• anal sex

And the only way to know your current STI status? Get STI screened after every new sexual partner.

If you’re pregnant

“When you’re pregnant the last thing you want is [foreign] bacteria to take over, so my opinion is that less [cleansing] is more,” Gersh says.

If you’re going through menopause

“After menopause the vulva skin may need more moisture because the skin and area will become more dry,” Gersh says.

She also recommends additional supplements to keep the skin moisturized from the inside out and outside in:

• vitamin E
• vitamin C
• multivitamin
• collagen protein

What about douching, steaming, and other trends?

Two words: Please don’t!

“Trends like douching and steaming may be fun to read about,” Streicher says, but they’re less than fun for your genitals.

“Not only are there absolutely no benefits to these trends, but doing them can actively cause harm,” she says.

Douching — the act of washing the vaginal canal with a water-soap or water-vinegar mixture — can alter the vagina’s natural microbiome.

And when that happens? “You take away the vagina’s natural defense against infections,” she says.

Vaginal steaming can also mess with these defenses. But even more painful and unsavory is the risk that it can literally burn your vaginal tissues and vulvar skin. Ouch!

Is there anything else you should avoid doing or using?

To be very clear: Anything marketed as “feminine hygiene” is a no-go.

Ditto goes for anything that claims to be “pH balancing.” “The vulva doesn’t need to be pH balanced, and the vagina is able to manage its own pH,” Streicher says.

Is there ever a time when you should see a doctor?

Yep! See a healthcare provider if you’ve noticed a change in look, feel, or smell, says Fosnight.

(Not sure how to notice a change? Scroll back up, darling!)

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Retinal vascular occlusion affects the eye, specifically the retina. The retina is the light-sensitive layer of tissue that lines the back of your eye. It’s covered with special cells called rods and cones that convert light into neural signals and send these signals on to the brain so you can see. The retina is vital for vision.

The vascular system includes blood vessels called arteries and veins, which transport blood throughout your body, including your eyes. Your retina requires a constant supply of blood to make sure your cells get enough nutrients and oxygen. Blood also removes the waste your retina produces. However, it’s possible for one of the vessels carrying blood to or from the retina to become blocked or to have a blood clot. This is called an occlusion.

The occlusion can cause blood or other fluids to build up and prevent the retina from properly filtering light. When light is blocked or fluids are present, a sudden loss of vision can occur. The severity of vision loss may depend on where the blockage or clot occurred.

Retinal vascular occlusion is a potentially serious condition, especially if hardening of the arteries, or atherosclerosis, already exists. It most often occurs in middle-aged and older people.

What are the different types of retinal vascular occlusion?

There are two types of retinal vascular occlusion. The type depends on which blood vessel is affected:

Retinal artery occlusion

Retinal artery occlusion is a blockage of one of the retinal arteries, which are blood vessels that carry oxygenated blood from the heart to your retina. A blockage in the main artery of your retina is called a central retinal artery occlusion. A branch retinal artery occlusion happens when the blockage occurs further along in the smaller branches of your artery.

Retinal vein occlusion

Retinal vein occlusion is blockage of one of your retinal veins, which are blood vessels that carry deoxygenated blood back to your heart. Retinal vein occlusion is also divided into two types:

• Central retinal vein occlusion (CRVO) is a blockage in the main vein of your retina, which is called the central retinal vein.
• Branch retinal vein occlusion (BRVO) occurs when the blockage is in a smaller branch of veins throughout the retina.

Blockages in your main vein or artery are often more serious than blockages in your branch veins or arteries.

Causes of retinal vascular occlusion

The specific cause of vascular blockage or blood clots in the retina is unknown. It may occur when the veins of the eye are too narrow. However, other factors that affect blood flow can put you at a higher risk of having retinal vascular occlusion. These risk factors include:

• atherosclerosis, or hardening of the arteries
• blood clots, which often travel from elsewhere in the body to the eye
• a blockage or narrowing in the carotid arteries of the neck
• heart problems, including irregular rhythm or valve issues
• diabetes
• high blood pressure
• high cholesterol
• being overweight
• intravenous (IV) drug use
• being over the age of 60
• glaucoma, which is a condition that damages your optic nerve
• smoking
• rare blood disorders
• macular edema, which is fluid buildup, swelling, and thickening of the central part of the retina
• inflammatory disorders such as giant cell arteritis

Symptoms of retinal vascular occlusion

The primary symptom of retinal vascular occlusion is a sudden change in vision. This could include blurry vision, or a partial or complete loss of vision.

The vision symptoms usually only occur in one eye. Physical pain is not a symptom of retinal vascular occlusion.

The changes in eyesight could be short term or permanent, depending on how quickly you seek treatment and if you have other health conditions. You should make an appointment with your ophthalmologist, or eye doctor, right away if you experience any changes in your vision. Definitely go to the emergency room immediately if you suddenly lose your vision in one eye.

Complications of retinal vascular occlusion

The condition can occasionally lead to complications and more serious symptoms. Vision may be severely and permanently affected if any of the following complications occur:

Macular edema is a swelling in the macula, or the central part of your retina, due to a buildup of blood.

Neovascularization is an abnormal growth of blood vessels caused by poor blood flow and a lack of oxygen to your retina.

Neovascular glaucoma involves fluid buildup and high pressure in your eye. This is a serious complication. It’s associated with severe vision loss and possibly loss of the eye.

Retinal detachment is rare. It’s a separation of your retina from your eye tissue.

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Diagnosing retinal vascular occlusion

Your ophthalmologist will perform a comprehensive exam to diagnose retinal vascular occlusion. They’ll check your vision, pressure within your eyes, and the physical appearance of your eyes. Your doctor will assess your eye function and the look of the pupil. They may also measure your blood pressure and suggest a blood test to check for blood clotting conditions.

The following eye tests may also be done:

• Optical coherence tomography (OCT) can be used to take a high definition image of your retina.
• An instrument called an ophthalmoscope can be used to examine your retina.
• In fluorescein angiography, a dye is injected into a certain vein in your arm. This vein is the one that travels to the blood vessels of the retina. Your doctor can use this to see what happens to the dye once it’s in your eye.

Your doctor may suggest other heart tests if they suspect blood clots are coming from somewhere else in your body. These tests may include an echocardiogram, electrocardiogram, and a heart monitor to check your heart’s rhythm. These tests will assess your heart and vascular.

Preventing retinal vascular occlusion

The best way to prevent retinal vascular occlusion is to identify and treat the risk factors. Since retinal vascular occlusion stems from vascular issues, it’s important to make lifestyle and dietary changes to protect your blood vessels and keep your heart healthy. These changes include:

• exercising
• losing weight or maintaining a healthy weight
• eating a healthy diet low in saturated fat
• not smoking or quitting smoking
• controlling diabetes by keeping your blood sugar at a healthy level
• taking aspirin or other blood thinners after consulting with your doctor first

Routine checkups with your doctor can help you learn whether or not you have any of the risk factors of retinal vascular occlusion. For example, if your doctor discovers you have high blood pressure or diabetes, you can start preventive treatment right away.

Treating retinal vascular occlusion

There’s no medication available that’s specific for retinal artery occlusions. Most people with this condition will have permanent changes to their vision.

To treat retinal vascular occlusion, your doctor may recommend medication such as blood thinners or injections into the eye.

Medications used to treat retinal vein occlusion include:

• antivascular endothelial growth factor (anti-VEGF) drugs such as aflibercept (Eylea) and ranibizumab (Lucentis), which are injected into the eye
• corticosteroid drugs that are injected into your eye to control the swelling

In some cases, laser therapy can be used to break down the blockage in the blood vessels and to keep more damage from occurring.

It’s possible to develop a blockage in your other eye. Your doctor will develop a prevention plan for you if they’re concerned that your other eye is at risk.

Outlook for people with retinal vascular occlusion

The outlook depends on the severity of your condition. Many people will recover and regain most of their vision capabilities, but not all. It’s possible that your vision will not return. Since retinal vascular occlusion typically only affects one eye, your brain may adjust to the change in vision after a few months. Once the eye adjusts, the loss of vision may become less of a problem for you.

If you have other eye conditions or complications from retinal vascular occlusion, such as complete vision loss or glaucoma, you may not fully recover your vision. You’ll need to work with your doctor to ensure that your eye conditions are managed properly.

The treatment of risk factors like diabetes and atherosclerosis dramatically reduces your risk of the occlusion recurring or causing further damage. In rare cases, a blood clot that continues to move throughout your bloodstream could cause a stroke.

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The aim of the rehabilitation is to aid the amputee to gain independence at the highest level they can, with the most efficient gait possible. The assessment must take into account the physical capabilities, level of amputation, psychological status, pre-amputation function, existing medical conditions and the patient’s expectations. Rehabilitation should begin 5 days post-surgery .  A crucial element of constructing a rehabilitation programme is sound gait analysis. This will largely be observational. Validated outcome measures are available to aid goal setting and measure function.

Gait analysis consists of observation of the gait, which should occur from all angles. Knowledge of normal gait patterns for the prosthetic and non-prosthetic user is required to help analysis of movement. On observation of the gait, the assessor compares the function of the amputee to expected patterns of gait and look for deviations. Analysis of the gait pattern will help determine why these deviations are occurring. This will then help to formulate the rehabilitation programme, which includes the correction of the deviations. Outcomes measures can be used to monitor progress.

Amputees should perform pre-prosthetic exercises to help maintain ROM and improve muscle strength in the lower limb and residual limb in preparation for using the prosthetic limb. Abdominal and back exercises should also be considered to help trunk control and reduce back pain. Pre-prosthetic limb exercises can help prevent the occurrence of prosthetic gait deviations.

Due to the loss of the limb, the amputee will automatically shift their centre of gravity over the foot of the non-prosthetic side. After an amputation, there will be a period of time where the amputee is without a prosthesis. This is due to the timeframe of the assessments required to decide if the provision of a limb is appropriate. During this period the amputee will become familiar with the shifted centre which will increase the difficulty of reorientation of the centre of gravity once they receive a prosthetic limb.

The authors of a systematic review study reviewed 18 manuscripts to evaluate the evidence on gait training interventions in patients with lower limb amputations, in order to guide both research and practice. They found that gait training is needed due to improve asymmetry, change in biomechanics, and related secondary consequences after an amputation. Both overground and treadmill-based rehabilitation was included for review. Their results showed that the following interventions are effective in improving gait: overground training (with verbal, manual, or psychological awareness interventions), treadmill-based training both as a supplement to overground, as a home exercise, or on its own with visual feedback or with body weight support.

The following exercises can be used for patients with either transtibial or transfemoral amputations and should be adapted as necessary, depending on the component. The prosthetic knee function could influence the exercises. If possible start with a locked knee or teach the patient to keep their centre of gravity on the prosthesis to keep it from bending when weight-bearing. Different prosthetic knees have different functions and specific ways to teach the patient. This page will give you the basics that can be used with every patient, with links at the bottom of the page to more specific rehab. You can also search on Google or YouTube for the specific company or prosthetic components information.

The Orientation of Centre of Gravity and Weight Bearing on the Prosthesis

Prosthetic training should include orientation of the centre of gravity and improve proprioception and weight bearing on the prosthetic side. There are a number of technique/exercises which can be employed to facilitate the rehabilitation of this:

Lateral weight shifting

Stand between parallel bars with two-handed support. The amputee practices shifting the weight from the non-prosthetic limb to the prosthetic side. This can be performed with pelvis only initially and progress to full-body movement when the amputee becomes more confident. This exercise will help the patient to contract his/her gluteal muscles and contract the muscles of their residual limb to stabilize. Make sure that the patient is actively engaging the muscles especially when the amputation is above the knee where the patient might lean into the socket (Trendelenburg stance) instead of using gluteus medius. A pair of scales under the feet can help to determine the weight transference. Two-handed support can be reduced to one-handed (alternating hands to the contralateral side of the weight shift) and fingertip support, for progression.

All the exercises below can be done with a gait belt and it is important that the therapist focuses on the patient’s safety and that all exercises are tailored to the patient’s ability and fall risk.

Forward and back weight shifting

Weight transference can be practised forwards and backwards to help balance and orientation. The exercise is performed as for lateral weight shifting but the body weight is moved forwards and back. This can begin with pelvic movements only to build confidence and progress to entire body weight. Reduced hand support will be a progression of this exercise. The patient should stand upright, with the feet hip-width apart and start by distributing their weight evenly between the two feet.

Stair/Stool stepping

Single leg stance on the prosthetic side can be improved by high stepping with the non-prosthetic side. With 2 handed support, the amputee steps the non-prosthetic limb onto a stool of approx. 4-8 inches. This exercise can be progressed by increasing the height of the step and/or reducing the hand support required, doing the movement slower, giving a bigger step on the sound side, and swinging the arms. The patient needs to actively engage the gluteals on the standing leg and avoid trunk side flexion. As the amputee becomes more confident and weight bearing improves the step of the non-prosthetic limb will be slower and more controlled.

Balance board

A balance board can be used to help weight bearing and balance where they shift body weight forward and back and laterally between the prosthetic and non-prosthetic side. This can be performed between parallel bars with 2 handed support and then progressed to 1 hand, no hands, movement of the arms, looking up and down, left and right, and catching and throwing a ball.

Throwing and catching

Stood between parallel bars or with supervision, as required the amputee performs throwing and catching with the therapist. This encourages the amputee to adjust their weight bearing as they reach outside their base of support over the prosthetic and non-prosthetic limb. This exercise can be progressed by the non-prosthetic limb being placed on a step or balance cushion. Make sure that the patient is safe. If the patient has a risk of falling make sure that they have a gait belt on and that someone is standing behind them.

Ball rolling

This exercise improves standing posture and balance. Start in the parallel bars and progress from there. The ball is placed under the sound limb, to work on muscle activation and weight bearing on the prosthetic side. Move forwards, backwards, sideways, and make circles. Progress by not holding on, increase the size of the ball, move faster, and change direction.

Single leg standing

Practice balancing on the prosthetic limb will help improve balance on that side. This can be performed with varying levels of hand support.

Kicking a ball

With or without hand support, standing on the prosthetic side, the amputee kicks a ball with the non-prosthetic leg to promote weight shift onto the prosthesis.

Single limb stand with Theraband

This exercise is done by tying the Theraband end around something sturdy and then around the prosthetic foot. Shift the weight to the sound foot and move the prosthetic side against the resistance of the band. Do it slow and controlled and in a straight line.

Gait Re-education

Specific gait re-education and facilitation is important during rehabilitation in order to ensure the correct biomechanics of gait are achieved. Recommendations are that gait re-education commences between parallel bars.

Walking aids

Rehabilitation should begin between parallel bars. However, once the amputee becomes confident and a good gait pattern is achieved walking aids should be introduced to aid the progression of mobility and to encourage mobility in the amputee home environment. Aids should be provided to promote the maximum level of independence and encourage the amputee to be as full weight bearing as possible. The patient’s pre-amputation level of function, current abilities, level of progression, overall health and medical status should be considered when selecting and progressing walking aids.

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Specific gait re-education

The gait cycle can be broken down and each segment practised with the amputee. With 2 handed support begin with heel strike of the non-prosthetic limb while weight bearing on the prosthetic side, encouraging correct foot placement. This is then practised with the opposite leg. Step by step progression of the gait should commence once heel strike is achieved. Forward weight transference onto and off the prosthetic limb to allow floor contact of the prosthetic foot and weight acceptance, without the swing through of the opposite leg, is the next step. This again is practised with both sides. Once this is satisfactory, swing through of the opposite leg can be practised when the leading foot/prosthesis is in stance. This process is followed with each step to help encourage a rhythmical, reciprocal gait pattern with appropriate weight shift. Regular proprioceptive facilitation to aid correct pelvic and trunk movements and help facilitate weight transference along with verbal feedback is used to reinforce correct movement.

Things to address during gait re-training.

1. Symmetrical width of walking base with weight transfer equal on sound and prosthetic limb
2. Stride length – usually patients will take a shorter faster step with the sound limb
3. Loading the prosthetic toe – dynamic weight bearing over the toe
4. Transverse pelvic rotation on the prosthetic side – resistance can be applied the ASIS to give feedback to the patient on what is required.
5. Prosthetic knee flexion
6. Trunk rotation and arm swing

Progressing from parallel bars to free walking

Sidestepping

This can be performed at any stage in the rehabilitation programme. The aim is to encourage lateral weight shifting and strengthen the abductors, The exercise can be performed with 2 hand support in the parallel bars and progress by the amputee moving around furniture/obstacles as a patient would in their own environment.

Backward walking

This activity is more difficult for transfemoral amputees than transtibial due to the lack of knee flexion of the prosthesis. However with practise the transfemoral amputee can perform this action with confidence. They will commonly need to plantarflex the ankle, come onto the toes, of on the non-prosthetic limb as they bring the prosthetic limb back.

Multidirectional changes

This will help improve prosthetic control and balance. Often changes in direction will prove difficult for amputees and practice will help improve mobility in more challenging environments such as crowded public places.

Tandem walking

This can help improve co-ordination, foot placement and weight bearing. A strip is placed on the floor. The exercise can be progressed through 3 stages

1. Foot placement on each side of the line
2. Foot placement heel toe along the line
3. Foot placement crossing over onto opposite sides of the line- for the more advanced amputee.

Braiding

The amputee stands with 2 handed support and swings one leg across the front of the body and then behind. This is performed with both the prosthetic and non-prosthetic side. To advance this exercise the amputee performs this action with more speed meaning they must adjust their weight bearing and balance to compensate for the speed of the movement.

Obstacle stepping

Between parallel bars or with supervision, the action of stepping over obstacles leading with the non-prosthetic limb can help encourage weight bearing on the prosthesis.

Functional Tasks

In addition to specific weight bearing and gait training, prosthetic rehabilitation should also include practice of more functional tasks of daily living. These should be centred on the patient’s individual goals.

Standing up from the floor

Stairs

The technique for performing stairs is the same for above and below knee amputees. Leading with the non-prosthetic limb ascending the stairs and descending with the prosthetic limb first. This can be progressed from 2 handed to non handed support, dependent on the ability of the amputee. Walking aids can also be used to help amputees manage stairs. Some prosthetic knees (hydraulic and microprocessor) allows step over step descending stairs by giving resistance during flexion,

Slopes/hills

Walking up and down slopes can be difficult for amputee patients. Often forward trunk flexion is required and shorted stride lengths. Some amputees will find it easiest ascending and descending slopes through side stepping. Aids and rails can aid with slopes. The same techniques in terms of stepping are applied to slopes as it is for stairs. Some prosthetic knees (hydraulic and microprocessor) allows a smooth step over step ramp descend by giving resistance during flexion.

Curb

The limb sequence applied to walking up and down stairs can be adopted for curbs. Walking aids are useful for assisting with curbs, however more advanced amputee will manage without. Balance and good single limb support is necessary for this. For the more advanced transtibial amputee the prosthetic limb can also be used to ascend curb and control descent.

Weight carrying

Practise walking with a weight on the prosthetic side or with objects in the hand. This may require a walking aid dependent on the patient’s ability.

Uneven surfaces

Walking over various terrains helps improve awareness and proprioception. It encourages the amputee to make use of their vision to compensate for the reduced proprioception on the prosthetic side.

Running

For advanced amputee running can be incorporated into the rehabilitation programme and can help amputees to increase participation in recreational activities.

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The aim of orthotics are to increase the efficiency of function during acute or long-term injury. This includes soft-tissue and boney injury, as well as changes as a result of neurological changes. They can be an effective adjunct alongside physiotherapy techniques such as muscle strengthening and stretches, gait and balance retraining and reach and grasp strategies.

A number of considerations need to be made before deciding on the type of orthotic needed:

• What are the patient’s goals?
• What are the specific impairments impacting on their function (thinking of head-to-toe and gait analysis).
• Are impairments the result of soft-tissue changes? Can they be changed with therapy input?
• Is a walking aid needed?
• Does the injury need to be protected from particular movements?
• Can an orthotic improve the efficiency of an activity?
• Can the patient cope with any adjuncts given?

Orthotics can be pre-made or customised, depending on the patient’s needs. 

“Off the shelf” Orthotics

Many patient’s can utilise ready made orthotics, which can often be adjusted to fit their size. These may come in small, medium and large sizes and can often be sized to the patient, e.g. with velcro straps. These are often lighter materials. They can also be good for an assessment, to confirm or deny a theory before a custom orthotic is made.

Custom Orthotics

Some individuals have more complex injuries / changes to one of multiple joint structures, and therefore require a customised orthosis. This may be particularly true in neurological conditions, such as Cerebral Palsy (CP), Parkinson’s Disease (PD) or after brain injury, such as traumatic brain jury (TBI) or stroke. In these cases, spasticity of muscles may have an impact on the patient’s function. Orthotics can be used both in resting and during mobility to improve affects of spasticity or reduce risk of contractures. In which case the orthotic will be specifically measured to the individual, and likely to be redone as the individual grows (in paediatrics) or as changes are made to joint structures.

Advantages

Lower limb: Influence both swing and stance phase of gait

• Prevent or correct deformity and reduce pain during weight bearing
• Improve efficiency of gait and maintain balance
• Improve base of support / lateral support
• Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
• To facilitate training in skills

Upper limbs: Can be used after an injury to prevent further injury, or reduced pain by supporting an injured limb.

• Prevent or correct deformity reducing pain and maximising function in reach and grasp tasks.
• In prove efficiency of reach and grasp tasks
• Off load an injured limb to allow healing
• Reduce need for compensation of ipsilateral and contralateral limbs and secondary pain
• Improve role of upper limb in maintaining balance

Spine: Stabalise spinal fractures to allow the patient to return to some normal activies (although they may be restricted) and protect the spinal cord.

Possible Complications

• Loss of sensation (check skin regularly- risk of pressure areas)
• Compensations in ipsilateral or contralateral limbs.
• Impact on spasticity (is the patient utilising spasticity to allow some function in absence of muscle strength?)
• Complications of casting at incorrect angle: Foot deformities, increased knee flexion in stance, muscle contractors
• Loss of sensory feedback and proprioception loss
• Ristricted range of motion
• Loss of natural shock absorption and long term joint damage
• Spinal orthotics must be put on and taken off within the guidelines of a spinal professional. Patients may be able to moblise within set restrictions, depending on the severity of their injury. Non-adherence to guidance may result in spinal cord injury.

Also, success depends on patient’s acceptance. Consider:

• Cosmesis
• Footwear
• Weight/rigidity
• Ability to Don Doff
• Compensations preferred
• Compensations required

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Types of Orthotics

Upper Limb

Healing

• Hinge-elbow brace: May be used to restrict elbow movement post fracture or surgery. Allows early mobilisation without damage to the healing tissue.

Hinge elbow brace: To restrict movement beyond a set degrees into flexion or extension to protect a healing injury / surgical site.

• Slings: Can be used after upper limb injury or surgery to protect the injury site. They can be used to restrict movements in particular directions to prevent further disruption to the injury (for example displacement of a fracture/ fixated bone). 

• Splints: Hand or wrist splints are often customised for individuals based on their specific impairment. This often achieved using thermoplastics. These can be both resting and functional.

Resting hand splint: Often customised to fit a patient to maintain range of movement in the hand for skin care and function.

Functional

• Wrist splint (e.g. fuctural splint)
• Elbow clasp: May be used, alongside exercises, especially if function is affected
• Neuromuscular Electrical stimulation (NMES):

Lower Limb

Orthotics can be used to optimise the alignment of the lower limb. This can be used to stabilise a joint to allow it to heal, or to facilitate ease of function. It can also be used to prevent or correct deformity in the lower limb, increasing efficiency.

Healing

• Wedge boot: Often used as conservative treatment or after surgery for Achilles tendon rupture to allow gradual stretching of the tendon as it heals. A heel wedge may also be used in patient’s with fixed platar flexion deformity to increased base of support and improve balance.

• Aircast boot: Often used after fracture injuries to support and reduce forces through the bone while healing. The air cells can be inflated around the foot and ankle, compressing the injury.

• Hinge-knee brace: Often used to protect knee surgery, such as meniscal repair.

• Splints; Patients with increased tone may require a resting splint to maintain optimal positioning of their lower limb and maintain a functional range in affected joints. Positioning and seated and supine positions are very important for these patients

Functional

• Ankle- Foot Orthosis (AFO): Correct alignment of the lower foot and ankle, which translates to the alignment of the shin, upper leg and pelvis. AFOs have an influence on both the swing and stance phase of gait. Can also be used to reduce risk of trips and falls as a result of foot drop.

• Lateral support ankle brace: In patient’s after ankle injuries, particularly to lateral ligaments, or neuromuscular disorders, a lateral ankle support may be needed. This brace has stiff lateral supports which will prevent excessive pronation or supination at the foot. This reduces the risk of further injury to lower limb structures, or injuries secondary to a fall.

Aircast lateral ankle support. To protect against lateral ankle strain and support lower limb in stance phase.

• Functional Electrical Stimulation (FES): In patient’s with central nervous system disorders / leisions, it may be possible, and safe, to use FES as a dynamic orthosis.Can be used on a number of muscle groups to simulate electrical impulses in peripheral nerves. It is often used to reduced impact of foot drop or knee hyperextension as a result of muscle weakness. There is also some evidence that it may contribute to strengthening of muscles. In this way, FES may reduce the patient’s risk of falls and has been shown to improve quality of life scores  

Functional Electrical Stimulation for lower limb function [illustration from wikimedia]

• Foot Orthotics: Custom orthotics can improve foot alignment by affecting muscle activity. Therefore, they improve efficieny in gait and balance, and minimise shock absorption through the lower limb, pelvis and spine. These corrective devices are placed in an individual’s footwear similar to insoles.

A trained health practitioner will complete a detailed assessment of an individual’s gait and foot position in both a static and a dynamic state to identify asymmetries. This information will be combined with a precise imprint of the feet on a foam cast. This will be sent off to a lab where the orthotics will be fabricated and created. Some facilities will also use a gait scan machine in order to analyse where the majority of your weight is dispersed while you heel strike and push off during the gait cycle. The foot specialist may request that the lab add special features to the orthotics based on the patient’s area of pain, the wear patterns in the patient’s shoes and the skin changes on their feet.

Consideration: It seems logical to think that pain in the foot region links directly to dysfunction in the foot region and that orthotics are the intervention of choice. Unfortunately, it is not always that straightforward. For example, could hip weakness or lower back pain be causing disruption to the gait cycle and compensatory strategies that place increased load on foot stuctures? It is important to determine what is “driving” the pain in the foot and to direct treatment to these structures to see if insoles are needed. Also, can the intrinsic muscle of the foot be trained either alongside, or instead of the use of insole orthotics?

Conditions that may require a foot orthosis as an adjunct include:
• Plantar fasciitis
• Morton’s Neuroma
• Flat feet or high arches
• Knee, hip or low back pain and SIJ dysfunction
• Degenerative Disc Disease and scoliosis
• Osteoarthritis
• Patellofemoral pain syndrome
• Femoral acetabular impingment
• Iliotibial band friction syndrome
• Bursitis
• Chronic ankle sprains
• Piriformis syndrome
• Achilles, Patellar, hamstring or gluteal tendinopathy and Snapping Psoas
• Recurrent Calf Strains

Spinal  Orthotics

Spinal orthotics can be used to give support to a spinal fracture. It is important to have clear instructions about the position that the patient should be in to put the brace on and off. This will be based on spinal scans and an multidisciplinary discussion of the stability of the spinal fracture.

A neck collar may be used for some patients where the fracture is stable, to provide comfort by supporting neck muscles and reducing pain. However, the benefits of a collar need to be weighed up against possible impact on the patient’s skin, their swallow and ability to feed themselves.

If a patient is discharged with a neck collar they will require a suitable collar care plan in the community to ensure their neck is cleaned and skin checked regularly. The soft pads of the neck collar will also need to be cleaned regularly. Therefore, spare pads should be provided to the patient.

Outcome Measures

Use of outcome measures will determine the effectiveness of orthotics. This will be based on the patient’s initial impairments, but may include:

• Neutral-0
• Passive range
• Active range
• Berg Balance Scale
• Tinetti
• Gait speed
• Timed up and go (TUG)
• Timed Unsupported Stand (TUSS)
• Functional gait assessment
• ARM A, B
• Action Reach Arm Test (ARAT)
• Reach and grasp
• Modified Ashworth Scale
• Patient perceived outcome measures

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