This ignores the fact that othopaedists will also include the fibula and tibia which are functionally part of the foot, being connected to it by the medial and lateral collateral ligaments – the ones you sprain when you twist your angle.
So that's 28.
Or the fact that the majority of adults have two additional sesamoid bones underneath their big toe, like miniature kneecaps.
So that's 30.
However …
These bones can commonly be bipartate, that is formed in two parts – so that makes 31 … or 32 – and other bones can also be formed in two parts.
However …
There are also dozens of of other, less common, anatomical variants including up to twenty other sesamoid bones, of which the most common is the os trigonum followed by other sesamoidal toe bones.
However …
You can also have extra bones – particularly toes (Anne Boleyn famously has six toes and fingers – and a supernumerary nipple – which helped fuel the assertion she was a witch). Extra toes can form in several ways, with a variety of extra bones forming.
And finally …
You are actually born with just 22 bones in your foot. Several of the tarsal bones are still just cartilage at birth that gradually develop into bone as you grow over the first decade or so of life. So children have fewer bones initially; however, some bones have more that one ossification centre, which makes it appear that, at some points in time, they have more than 26 bones … or 30 bones … or (my favourite answer), "lots".
Thanks to all who took part.
IS MY SHOULDER PAIN SHOULDER PAIN?
As with so much in life, clinical routine has its seasonal features: the overindulgence accident at Christmas; the gardener’s back in March after a winter of inactivity – most of these problems have an obvious cause an effect but there is one problem that strikes every autumn … and nobody is quite sure why.
Ask a chiropractor how they know when autumn has arrived and they will tell you it’s the sudden influx of patients with ‘shoulder’ pain – instead of half-a-dozen per week, suddenly it’s more than half a dozen every single day.
Theories as to why range from the ‘cold wintery draught on warm skin’ to the effects of rapidly changing day length on serotonin levels, though no theory has yet been proved (it’s not a well-researched subject). What is, however, seems quite clear from clinical experience is that most of these seasonal symptoms are not shoulder pain at all!
If the pain is across the top of your shoulder or between the shoulder blade and the spine, then the chances are it’s coming from your ribs. Patients often look slightly sceptical on being informed that their ‘shoulder’ pain is coming from their costal joints (the joints between the ribs and the vertebrae) – “surely my ribs are in my chest?” they say. In fact, the top rib actually joins with the base of the neck and acts as an anchor for some of the big muscles that run up the side and back of the neck (which can often feel as if they’ve been ‘pulled’ or ‘cricked’ if the underlying rib is injured). You can easily feel your top (first) rib, it’s the bony lump you can feel at the base of your neck just behind your collar bone … that’s how high they go.
By comparison, most pain that arises from the joints and muscle of the shoulder is typically felt at the top of the arm. either whether the rotator muscle pass under the collar bone and attach to the arms or coming directly from the joint between the collar bone and shoulder blade or from the cartilage, ligaments and synovium of the ball and socket joint.
The other things patients often complain of is that – unlike ‘true’ shoulder injuries – they’ve no idea how they’ve done it: it just “came on gradually”, or, more commonly, they “woke up with it”. That’s because the inflammation in the small joints between the ribs and the spine builds up slowly over several hours, so its not the injury (often from lifting at arm’s length) that hurts, it’s the body’s reaction hours later.
So, if you’ve got a intense ache across the top of your shoulder or feel there's a knife in your back just inside the shoulder blade, then you’re probably suffering from costovertebral syndrome, colloquially known as a ‘popped rib’ … and you may well be suffering: it can be one of the most painful of conditions; fortunately, it is also one of the easiest and quickest for chiropractors to treat, with recovery often in days.
There's also something you can do to help yourself if you’re suffering from seasonal shoulder symptoms, use an ice pack (or wrap some frozen peas in a tea towel) and apply for ten minutes or so every hour (that will reduce the inflammation), then pick up the phone and ask one of our chiropractic experts for confirmation that it’s your ribs and not your shoulder that are the source of the trouble.
Chiropractors treat a lot of headaches, it’s a daily presentation and most patients are chronic sufferers who have tried remedy after remedy and have formulated a cocktail of pills, potions and routines to keep themselves functional.
It is sometimes hard to explain to someone who doesn’t suffer from headaches or migraines what it’s like but try to imagine having a really bad hangover … only without any of the preceding pleasure and with the knowledge that it isn’t going to feel any better after coffee and aspirin, or indeed any time soon.
But what causes headaches? And how can chiropractors treat them?
The first thing to realise is that a headache isn’t an illness, it’s a symptom –and it’s a symptom that can have dozens of different causes. As a clinician, one of the first jobs in establishing a diagnosis is to rule out any sinister causes: tumours, vascular problems and diseases such as temporal arteritis are rare but you can’t afford to miss them.
So if the brain isn’t the pain, what is? Well, there is one structure inside your skull that isn’t just good at causing pain, it’s the most pain sensitive bit of your body – the lining of the brain, called the dura (actually, it’s really three structures but that’s just making thinks more complicated than they need to be). This is what becomes inflamed in meningitis – and to a lesser extent in flu – and, if you’ve ever had one of those headaches, you’ll appreciate exactly what misery it can cause.
The same sheet of material that wraps around the inside of your skull also wraps around the spinal cord as it descends through the vertebrae in your back – and it has a particularly strong attachment to the inside of the top three vertebrae; these attachments are know as the durovertebral ligaments. If the vertebrae are twisted out of position or otherwise dysfunctional, it can not only cause pain in the back of the head but can also seemingly pull on the dural attachments at the front of the skull, particularly across the forehead and behind the eyes.
When we’re stressed, our body language changes and our head position is much further forwards. This can easily double or even treble the strain on your cervical spine – which is why this type of headache tends to be dubbed a ‘stress’ headache.
This, unfortunately, is not the only head pain that stress can cause. Trigger points from the sub-occipital muscles – a small group of muscles that run between the top two vertebrae and the base of the skull – can also develop painful knots called ‘myofascial trigger points’. Not only can these case pain in the back of the head, they also have a classic referral pattern giving the tight band around the entire skull – a ‘tension headache’ … and there are half a dozen other muscles that can also produce head pain, all with their own referral patterns.
There is also quite strong evidence that a third type of headache – this time a migraine, affecting just one side of the head – can be caused by upper cervical spine joint dysfunction. The mechanism behind this is the subject of some controversy, whether it is referral from an injured facet joint in one of the top three vertebrae or a ‘trapped nerve’ (actually interference with the nucleus of the nerve to the forehead and face); however, it seems clear that the neck is the direct source of the problem, which is why these headaches are known as ‘cervicogenic migraines’.
There is also condition in which a nerve genuinely does get trapped: greater occipital neuralgia. This nerve has to pass between the top two vertebrae and supplies the back of the skull, which is where it causes the headache (on one side only) when it gets trapped. Although it’s almost entirely unresearched, I’ve never seen a ‘trapped’ great occipital nerve that couldn’t be ‘untrapped’.
So by now, you’ve probably gathered that the top of the spine can cause a lot of … well … headaches – and that stress can be a big trigger. It is not, however, just head position and muscle tension that can cause dysfunction in this area – your teeth can also do so! If you’re a clencher or a grinder (and you may be doing it at night without even realising it), and your occlusion is unbalanced, then the asymmetrical muscle tension can also cause rotational forces through the neck and shoulders … and guess what that causes? That’s right, the joint and muscle problems that we’ve just been talking about (or dehydration!).
It took me several years to work out why it was that not all of my headache patients got better, even when I was sure I had got the diagnosis right, and several years more to start working with an orthodontist and a psychotherapist to make sure that those patients who had poor occlusions and/or were overly stressed could get the joint management (pardon the pun) that they needed.
There is one other form of headache that this collaboration has seemingly helped treat, although once again the hard clinical ‘proof’ is lacking because nobody has done the research – cluster migraines, also known as ‘suicide headaches’ because the pain and frequency of attacks can drive a person to that level of despair.
I had a vested interest in discovering as much as I could about these headaches as my father-in-law had been a sufferer in the past and started getting attacks again not long after I married his daughter. I read an interesting theory that the headaches were caused by temporalis muscle spasm and the reason the pain was so bad was that the tendons of the muscles insert no just into the temporal bone but into the sutures around the bone where, in some people, they go deep enough to meet the dura mater, which also runs up into the sutures from the inside … when the first starts putting pressure on the second, it’s as if you were squeezing the body’s most sensitive tissue in a vice.
The solution was to deal with the cause of the spasm (a worn pain of ancient dentures causing his bite to be ‘overclosed’) and release the muscles. One happy father-in-law.
“So what about food intolerances,” I can hear readers scream, “Or hormones!” Pretty much the only other pain sensitive structures in the brain are the blood vessels, particularly the muscular wall of arteries, quite of few of which run within … yes, the dura. Anything that causes pressure on the dura – such as the changing diameter of an artery – can trigger pain, particularly if the dura is already under tension from the external causes we’ve been discussing.
This fits well with the concept many chiropractors use of a ‘physiological adaptive range’ within which things can go wrong without causing pain but as different factors erode that ‘healthy’ range (diet, lifestyle, trauma, illness, environment), it can tip you over the edge. Get as many of those things right as possible, and you not only get rid of the symptoms but restore enough of the adaptive range for you to soak up the daily pressure of living without it triggering a headache.
This is part of the reason that chiropractors don’t just train in diagnosis and physical therapy but also in nutrition and psychology – which makes a chiropractor a good place to start if you’ve got a headache.
This ignores the fact that othopaedists will also include the fibula and tibia which are functionally part of the foot, being connected to it by the medial and lateral collateral ligaments – the ones you sprain when you twist your angle.
So that's 28.
Or the fact that the majority of adults have two additional sesamoid bones underneath their big toe, like miniature kneecaps.
So that's 30.However …
These bones can commonly be bipartate, that is formed in two parts – so that makes 31 … or 32 – and other bones can also be formed in two parts.
However …
There are also dozens of of other, less common, anatomical variants including up to twenty other sesamoid bones, of which the most common is the os trigonum followed by other sesamoidal toe bones.
However …
You can also have extra bones – particularly toes (Anne Boleyn famously has six toes and fingers – and a supernumerary nipple – which helped fuel the assertion she was a witch). Extra toes can form in several ways, with a variety of extra bones forming.
And finally …
You are actually born with just 22 bones in your foot. Several of the tarsal bones are still just cartilage at birth that gradually develop into bone as you grow over the first decade or so of life. So children have fewer bones initially; however, some bones have more that one ossification centre, which makes it appear that, at some points in time, they have more than 26 bones … or 30 bones … or (my favourite answer), "lots".
Thanks to all who took part.
As with so much in life, clinical routine has its seasonal features: the overindulgence accident at Christmas; the gardener’s back in March after a winter of inactivity – most of these problems have an obvious cause an effect but there is one problem that strikes every autumn … and nobody is quite sure why.
Ask a chiropractor how they know when autumn has arrived and they will tell you it’s the sudden influx of patients with ‘shoulder’ pain – instead of half-a-dozen per week, suddenly it’s more than half a dozen every single day.
Theories as to why range from the ‘cold wintery draught on warm skin’ to the effects of rapidly changing day length on serotonin levels, though no theory has yet been proved (it’s not a well-researched subject). What is, however, seems quite clear from clinical experience is that most of these seasonal symptoms are not shoulder pain at all!
If the pain is across the top of your shoulder or between the shoulder blade and the spine, then the chances are it’s coming from your ribs. Patients often look slightly sceptical on being informed that their ‘shoulder’ pain is coming from their costal joints (the joints between the ribs and the vertebrae) – “surely my ribs are in my chest?” they say. In fact, the top rib actually joins with the base of the neck and acts as an anchor for some of the big muscles that run up the side and back of the neck (which can often feel as if they’ve been ‘pulled’ or ‘cricked’ if the underlying rib is injured). You can easily feel your top (first) rib, it’s the bony lump you can feel at the base of your neck just behind your collar bone … that’s how high they go.
By comparison, most pain that arises from the joints and muscle of the shoulder is typically felt at the top of the arm. either whether the rotator muscle pass under the collar bone and attach to the arms or coming directly from the joint between the collar bone and shoulder blade or from the cartilage, ligaments and synovium of the ball and socket joint.
The other things patients often complain of is that – unlike ‘true’ shoulder injuries – they’ve no idea how they’ve done it: it just “came on gradually”, or, more commonly, they “woke up with it”. That’s because the inflammation in the small joints between the ribs and the spine builds up slowly over several hours, so its not the injury (often from lifting at arm’s length) that hurts, it’s the body’s reaction hours later.
So, if you’ve got a intense ache across the top of your shoulder or feel there's a knife in your back just inside the shoulder blade, then you’re probably suffering from costovertebral syndrome, colloquially known as a ‘popped rib’ … and you may well be suffering: it can be one of the most painful of conditions; fortunately, it is also one of the easiest and quickest for chiropractors to treat, with recovery often in days.
There's also something you can do to help yourself if you’re suffering from seasonal shoulder symptoms, use an ice pack (or wrap some frozen peas in a tea towel) and apply for ten minutes or so every hour (that will reduce the inflammation), then pick up the phone and ask one of our chiropractic experts for confirmation that it’s your ribs and not your shoulder that are the source of the trouble.
Chiropractors treat a lot of headaches, it’s a daily presentation and most patients are chronic sufferers who have tried remedy after remedy and have formulated a cocktail of pills, potions and routines to keep themselves functional.
The same sheet of material that wraps around the inside of your skull also wraps around the spinal cord as it descends through the vertebrae in your back – and it has a particularly strong attachment to the inside of the top three vertebrae; these attachments are know as the durovertebral ligaments. If the vertebrae are twisted out of position or otherwise dysfunctional, it can not only cause pain in the back of the head but can also seemingly pull on the dural attachments at the front of the skull, particularly across the forehead and behind the eyes.
When we’re stressed, our body language changes and our head position is much further forwards. This can easily double or even treble the strain on your cervical spine – which is why this type of headache tends to be dubbed a ‘stress’ headache.
This, unfortunately, is not the only head pain that stress can cause. Trigger points from the sub-occipital muscles – a small group of muscles that run between the top two vertebrae and the base of the skull – can also develop painful knots called ‘myofascial trigger points’. Not only can these case pain in the back of the head, they also have a classic referral pattern giving the tight band around the entire skull – a ‘tension headache’ … and there are half a dozen other muscles that can also produce head pain, all with their own referral patterns.
There is also quite strong evidence that a third type of headache – this time a migraine, affecting just one side of the head – can be caused by upper cervical spine joint dysfunction. The mechanism behind this is the subject of some controversy, whether it is referral from an injured facet joint in one of the top three vertebrae or a ‘trapped nerve’ (actually interference with the nucleus of the nerve to the forehead and face); however, it seems clear that the neck is the direct source of the problem, which is why these headaches are known as ‘cervicogenic migraines’.
There is also condition in which a nerve genuinely does get trapped: greater occipital neuralgia. This nerve has to pass between the top two vertebrae and supplies the back of the skull, which is where it causes the headache (on one side only) when it gets trapped. Although it’s almost entirely unresearched, I’ve never seen a ‘trapped’ great occipital nerve that couldn’t be ‘untrapped’.
“So what about food intolerances,” I can hear readers scream, “Or hormones!” Pretty much the only other pain sensitive structures in the brain are the blood vessels, particularly the muscular wall of arteries, quite of few of which run within … yes, the dura. Anything that causes pressure on the dura – such as the changing diameter of an artery – can trigger pain, particularly if the dura is already under tension from the external causes we’ve been discussing. How to avoid Christmas being a pain in the …
Of all the clinics of the year, the ones immediately after Christmas are the one that stirs the most emotions. Although we’re used to a wide range of presenting complaints, the ones following the season of festive brouhaha, are often the most bizarre but often reflect how a family’s seasonal holiday was ruined by avoidable injury.
Most existing patients are rightly keen to prevent this, which is why the December patient lists are groaning at the seams as people book for ore-Christmas check-ups or finally resolve to fix the niggles that may have been mothering them for days, all to be right for the Big Ho-ho-ho.
So what steps can you take to avoid musculoskeletal misery over Yule tide?
• Don’t stress yourself out. Christmas is often a time that we spend with people we feel we ought to rather than people we want to – and emotional stress causes muscular tension far more often that it puts your blood pressure up. Plan to be cheerful and polite but build in some solitude time so the effort doesn’t have to be constant: anything from a soak in hot tub to testing out the kids’ new headphones.
• The one thing we all tend to do more at Christmas is be sedentary – be it standing for hours peeling the sprouts or slumped on the sofa watching Downton Abbey. Prolonged standing and sitting are both bad for the spine, so vary your position and take every opportunity to move about, preferably before it starts to hurt!
• When we do finally decide that we’ve spent too long indoors, what do we do? Go out for an over-ambitious Boxing Day family ramble with no thought as to how far each member of the group might be able to walk comfortably, and often we chose places that are guaranteed to cause backache: walking on broken surfaces such as shingle beaches or through thick mud will often trigger low back problems – the key rule: little and often beats seldom and long!
• Most people’s Christmas includes a tipple … or three. But if you don’t want it to lead to injury, then DO mix your drinks: intersperse an alcoholic drink with a soft one, and put a glass of mineral water next to your wine on the dining table (as all #5steppers know). Alcohol induced injuries include falling asleep in awkward positions, muscular dehydration and falls.
• The final danger – and one that often strains the physician’s straight-face – is the over-exuberant unaccustomed activity. Every year we see uncles who thought they could beat their niece at Twister; Wii-induced Granny pains from the expectation that they could play living-room tennis in the same way as they did the real thing half a century ago; pulls, twists and sprains from over-ambitious romance gone wrong (you don’t have to lift someone off their feet to kiss them under the mistletoe) and no Dad should be allowed to dance after more than 5 units of alcohol (if at all).
What should you give your body for Christmas?
The average lifespan of a mattress is about seven years, even with regular turning, though a top of the range model might last twice as long … and you won’t get one of these for under £1,000. You might baulk at spending that much on a mattress but ask yourself this: How much did you spend on your three-piece suite? – and how long do you spend sitting on it compared with the amount of time you spend in your bed?
The right office workstation can make all the difference. Your office chair should have adjustable height, tilt and a sprung back; it should have arms that are level with the top of your desk. Typically such a chair will set you back around £120 – and it costs even less to make sure your screen is at the right height and that you’re using the right hardware: a trackball can put so much less strain on your arms and shoulders than a mouse for half the price of a chiropractic treatment.
What should you give your body for Christmas?
You’ve ordered the turkey, hung the stockings and wrapped the presents. Chances are you’re either feeling footsore or your neck is stiff; your back may be giving out alarming twinges as you decorate the tree or your shoulders can’t reach to hang the mistletoe; your knees might be making alarming sounds as you squat down to put warm ham in the oven or the sciatica could be protesting at sitting through the Christmas Downton Abbey special.
At any one time, a third of
• Do you need a new mattress?
The average lifespan of a mattress is about seven years, even with regular turning, though a top of the range model might last twice as long … and you won’t get one of these for under £1,000. You might baulk at spending that much on a mattress but ask yourself this: How much did you spend on your three-piece suite? – and how long do you spend sitting on it compared with the amount of time you spend in your bed?
• And how about a pillow to go with it?
One of the questions we’re asked most often is ‘which pillow should I use?’. The problem is there’s no easy answer to this … trial and error tends to lead to the best solution. There are hundreds of ‘orthopaedic’ pillows on the market and the best way to tell if it suits you is to use it. This can be expensive, which is why we keep a stock of pillows for (non-smoking) patients to try (smokers’ breath makes the pillow unusable after a fortnight’s trial). The rule is that a pillow should keep your neck in line with the rest of your spine – which will also depend on how hard your mattress is – and remember goose down may well be better than the most modern hi-tech materials.
• And when you’re awake?
The right office workstation can make all the difference. Your office chair should have adjustable height, tilt and a sprung back; it should have arms that are level with the top of your desk. Typically such a chair will set you back around £120 – and it costs even less to make sure your screen is at the right height and that you’re using the right hardware: a trackball can put so much less strain on your arms and shoulders than a mouse for half the price of a chiropractic treatment.
• Prevention is better than cure
We spend a lot of time discussing with patients how to prevent problems. We have masseuses in all our clinics to prevent the build-up of muscle tension and an Alexander Technique practitioner to remedy postural problems and we prescribe exercises to move fibrosis and improve stability.
• Put it right
If it hurts, it’s because something’s wrong. If it keeps on hurting, it’s because there’s too much wrong for your body to heal – which is when you need a helping chiropractic hand.
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