So how many bones ARE there in a human foot?

Those of you who participated in our Facebook teaser may wonder why totting up the number of bones in the picture didn't automatically equate to a correct answer (26).

If you open a basic anatomy textbook (or Google the question 'how many bones are there in the human foot' then this is, indeed, the answer you are likely to get:

• Seven tarsal bones (Medial, intermediate and lateral cuneiforms; cuboid, talus, navicular, and calcaneus).
• Five metatarsals
• Fourteen palanges – the big toe only has two, the other toes have three (actually to an embryologist, they all have three: the medial cuneiform starts life as a metatarsal; the navicular, which forms the keystone of the longitudinal arch, as a cuneiform and the metatarsal in actually an elongated proximal phalanx).

Total 26.


However …

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.

What does a chiropractor do … on a Wednesday

Normally Wednesday is the one working day when I spend the whole day in the same clinic … which means I actually get a lunch hour – or more accurately 56 minutes in which to meet with my practice manager, make phone calls, write emails and do the 1001 other things associated with running four clinics and 4 minutes to wolf down a sandwich.

On some Wednesdays I run a specialist headache clinic with two colleagues – an orthodontist (Mark Brickley) and a psychotherapist (Judith O’Hagan) – in which we get to grips with the complicated sort of problems that cause seemingly intractable head and face pain, but which will often respond to a combined approach in cases where no one individual could hope to be effective (http://www.theheadacheclinic.co.uk/index.html). 

Many headaches and migraines come from musculo-skeletal structures (joints, nerves, muscles and ligaments) but if someone is tense, stressed, depressed, clenching their teeth, has an unbalanced occlusion or forward head posture, then they can often undo all a chiropractor is trying to correct within hours … or sometimes even minutes. That’s when identifying the component parts of the problem then treating the mind, balancing the occlusion and preventing the clenching allows the adjustments and exercises prescribed by the chiropractor to start working. Headache clinic days are always great days because you get to work with fascinating people on challenging and interesting patients – I also get to sit down to eat lunch before we start, although this brief period of relaxation is somewhat countered by having to fit three clinics into one day.

This week however, I was not in clinic at all on Wednesday.

Like all regulated healthcare professionals, chiropractors have to complete a minimum amount (30 hours) of continuing professional development every year in order to maintain their professional registration. Even if we didn’t, I would still go to the AGM of the Royal College of Chiropractors … in fact I have been to every AGM since the very first in 1997 (bar last year’s when it was oversubscribed and I couldn’t get a place … so popular and important have they become).

The Royal College of Chiropractors (http://rcc-uk.org) is – and will probably remain – the most important thing that has happened to chiropractic this century.  Much like the passing of the Chiropractors’ Act in 1994, which paved the way to statutory regulation, the setting of minimum educational standards, a Code of Practice and protection of title (when I graduated, anyone could style themselves a chiropractor), the granting of a Royal Charter to the College of Chiropractors in 2012 was a pivotal moment … I don’t think may people yet recognise how pivotal.

For the first time, the chiropractic profession has recognised specialists developing their post-graduate skills though Faculties (of Pregnancy & Paediatrics, Orthopaedics & Rehabilitation, Sports & Exercise, Animal Chiropractic and my own area of specialism, Pain).  The AGM always kicks off with the Faculty AGM’s … this year’s Pain Faculty was taken up for the most part with development, as befits the College’s youngest faculty.  

The discussions were wide-ranging: the new NICE Guidelines for Low Back Pain & Sciatica (https://www.nice.org.uk/guidance/NG59) again include spinal manipulative therapy and exercise and amongst the few therapies that actually work (good news for chiropractors and osteopaths); however, acupuncture is no longer included – although it will, I hasten to add, continue to be offered as part of our treatment packages despite this. 

I pointed out to the meeting that the entire basis for the decision was fundamentally flawed: acupuncture has many different schools with very different approaches (we use medical acupuncture – also known as ‘dry-needling’ – to treat myofascial pain syndromes) and low back pain and sciatica are not diseases but symptoms which have many different causes, some of which will respond and some of which may not. (http://docmartin99.blogspot.co.uk/2015/02/sciatica-is-not-only-condition-thats.html)

What can be said with certainty is that myofascial pain syndromes are an invariable part of almost all low back pain, whatever its cause, and there is abundant evidence that dry-needling is highly effective in treating the trigger points responsible for the pain. The Guidelines therefore demonstrate a failure of joined up thinking … so I got volunteered to write an article for the College’s journal explaining this in scientific terms.

The Faculty also needed a Secretary – and as I was going to clearly be doing some writing anyway … I got volunteered for that too.

And I though I’d got better at saying ‘no’!

The afternoon’s programme comprised the President’s Lecture, delivered by Dr Sarah Goldingay  (http://humanities.exeter.ac.uk/drama/staff/goldingay/) – always good to hear from the great and the good outside of the profession – and then presentations from researchers being funded by the College … it’s nice when you listen to old friends speaking and think of them as ‘my ex-squash partner', ‘my MPhil supervisor’ or ‘someone I used to teach’, rather than Professor this or Dr that.

It also made me realise how cutting edge much of what chiropractic is now doing can be – and how it contrasts with some elements of the profession (mostly imports from countries which ought to know better but apparently don’t) who regard the General Chiropractic Council as a nuisance and want to go on delivering care based on benefit to their bank balance using protocols based on 19th century metaphysics.  

I recall an old dentist telling me many years ago when I was still at College that it took dentistry 50 years to move from being an unregulated profession to being fully respectable … we’ve only had 16 years but at least  (unlike the dentists) we have our own Royal College setting standards to which increasing numbers of chiropractors aspire. 

I for one have reached the stage where my most cherished post-nominals (those long list of letters that professional people put after their name to show how professional they actually are) are the four letters ‘FRCC’ (actually I can put these twice because I am both an ordinary Fellow and a Fellow of the Faculty of Pain, but that would be showing off). 

This is for the simple reason that all my other degrees and qualifications are what has allowed me to become a Fellow of the College – and the College stands for the quality, rigour and clinical governance that is, I hope, inherent in our clinics’ daily treatment of patients.

So how can your neck give you a headache?

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?

What does a Chiropractor do … on a Tuesday?

Because I work on Saturdays and have Mondays off, Tuesdays start early at 7:30 and begin with an assault on the in-tray: two days’ post, messages, following up patients, phone calls and making sure the social media for the week is planned and posted (thanks goodness for Hootsuite and ‘autoschedule’).

It’s important that the decks are cleared before patients start, because Tuesdays are invariably fully booked … and often overbooked, as was this particular Tuesday, which kicked off fifteen minutes early with an emergency patient, who had cricked their neck sleeping awkwardly the previous day and was nervous about seeing another chiropractor.

The morning consisted of a typical mix of patients: There were twelve cases of low back pain (including one new patient), one hip pain, one ankle injury (tennis), a couple more cases of cervicalgia, and a couple of headache, a child with poor gait, a cartilage injury in the knee, a rotator cuff tendinitis and a lady with temporomandibular disorder … and one no-show, which is always incredibly frustrating when you’re not only full but have people on the waiting list, desperate for appointments.  Fortunately, everyone was getting better and staying better apart from one of the headache patients, who was referred to our next specialist Headache Clinic so the dental and stress components that were preventing the condition from settling could be addressed.

Although I always try to run to time, the last couple of patients proved slightly more complicated than expected and that made lunchtime a bot of a scramble – Tuesday’s morning session is at Yeovil and the afternoon session is at Crewkerne … which gives me the opportunity to stop at home en route and quickly eat a rather belated lunch.

As ever, when time is tight, the traffic on East Street is backed up to Mount Pleasant (someone build a bypass for Crewkerne PLEASE!!) and clinic starts seven minutes late!  This, of course is the immediate cue for patients to be complicated, refactory, or to present with unexpected new conditions.

The first patient was typical of this, a lady with a recovering sacroiliac joint causing buttock pain who had been feeling so much better that she decided to move some furniture and now had raging sciatica and all the signs of a prolapsed lumbar disc.  The next three patients also all had sacroiliac joint problems; however, these were all recovering as per prognosis – improved after three treatments, better after six and two of the patients were ready to start some gentle home-based exercises to stretch out tight, fibrotic muscles and rebuild core stability.

The next case is a tough one – a whiplash injury that has been referred via a solicitor having previously failed to recover.  The delays involved in processing the claim has allowed the injury to become chronic and it’s not just neck pain, like a lot of whiplash there is also a jaw problem (which is preventing the neck from settling), back pain and a shoulder injury … all made worse by the stress of dealing with solicitors and the whole compensation process. Today, at last, there is some sign of improvement: everything is moving better and hurting less – but with so many areas to treat, there is no chance of catching up and now I’m running almost quarter of an hour late.There is, however, no point in worrying about that … most patients understand that sometimes you need to spend longer with a patient – next time, it could be them! 

Fortunately, the next lady in is a new patient: at last a chance to sit down for a few minutes and to take a case history. Fortunately too, her case is relatively straightforward: a long history of migraines, which sound like they’re coming from the neck with no evidence of anything sinister or untoward going on – the physical examination confirms the diagnosis and there’s time to start a course of treatment which turns out to solve fifteen years of weekly misery in just  couple of weeks!

The rest of the evening is full of complicated patients: a knee riddled with osteoarthritis that would probably do better with surgery but the lady’s determined to avoid the kind at all costs; neck pain in an eighty-four-year old lady with osteoporosis who needs particularly careful handling; another case of low back pain following not one but two car accidents (the neck and jaw had already responded to treatment); a lady with back hip and knee pain; a cervical disc injury causing arm pain and, to finish the day, a disc problem which is stubbornly refusing to respond to treatment and needs referral for magnetic resonance imaging in Bridgwater, where we have a special arrangement … all of which means that clinic finishes fifteen minutes late – which is still quarter of an hour earlier than the rest of the week (for historical reasons, Tuesday’s Crewkerne clinic ends at 6:30 rather than 7).

Home at 7pm having left at 7am. Although there is stuff to be done (when isn’t there?), the lure of an early night proves irresistible: tomorrow is going to be another early start with budgets, cashflow forecasts and marketing analysis all to do before another 36-patient day and a fresh brain will be required.

What does a Chiropractor do … on a Sunday?

What does a chiropractor do?

That’s a question I often get asked – even people who’ve been through a course of treatment only get a snapshot of a typical clinical day as it relates to their presenting condition … and life as a chiropractor can involve so much more than just turning up and treating patients.

I decided to keep a journal of different days of the week for three months – and then pick one entry for each day of the week at random.

Here’s what I got up to.

A day of rest it isn’t.

As anyone with an eight-year-old will know, Sunday usually begins several hours before dawn as they wake up a good two hours earlier than on weekdays and sneak in to make sure you’re enjoying your lie in.

There is then the after breakfast (bacon, sausage and black pudding butties  – #5stepping is about moderation in all things including moderation) dash to some remote corner of Somerset to collect whichever teenager needs extracting from sleeping over after a play/match/concert/party in time for coffee at Granny and Grandad’s.

Another question I often get asked is what it’s like to work alongside your mother.  The answer is I don’t know – we’re now only in the same clinic at the same time once a week, and she spends her time in her treatment room from 9 till 7, whilst I’m in mine for the same period: if we need a meeting, we have to schedule it … or we get a chance to chat over coffee in between grandchildren and crosswords on a Sunday morning.

Sunday afternoon is dilemma time: family first as it’s our only day together – but there’s also gardening (once a whole family activity but no more) and those little bits of work that you didn’t get done during the week and which you feel guilty for doing and guilty for not having done.

Today though there’s a major – and highly complex – medicolegal report that’s needed by tomorrow and at the 6,200 words I managed to write between 142 patients last week, I’m only halfway finished. These days I have every speed device known to mankind [try TextExpander if you need to type long, technical phrases on a regular basis] and can manage 1,000 words an hour unless I’m on a particularly difficult area … which means I can finish the report and still find time for Harry Potter, help with homework, diary planning for the coming week, five emails from patients and the last ten minutes of Downton Abbey.

At least on Monday, you can guarantee that the eight-year-old will need waking up after the alarm goes off at 6!

Arthritis – Should I learn to live with it?

 Arthritis is another of those words that mean different things to different people. To most, it means your joints have got a bit of wear and tear in them; to a specialist such as a rheumatologist or chiropractor, arthritis refers to a very specific group of much rarer inflammatory diseases of which rheumatoid arthritis and anklylosing spondylitis are probably the best known. Wear and tear – often referred to as ‘osteoarthritis’ – is a completely different disease process, which is why specialists prefer the term ‘degenerative joint disease’, or DJD for short.

So do you have DJD?  If you’re over 50, then the answer is almost certainly “yes” – most commonly, it affects the joints that we use the most (thumbs, toes, backs and necks) or the ones that bear the most weight (hips and knees), particularly if you’re carrying extra poundage!  So if you’ve got some swelling or stiffness in those joints, can you do anything about it?

My Shoulder is Frozen!

Have you ever had a shoulder joint that’s painful and restricted?  The chances are you probably thought it was a ‘frozen shoulder’ – and the chances are you were probably wrong!

As with some of the previous terms we’ve discussed, such as sciatica and migraines, the problem lies in part with the difference between what you might mean by ‘frozen shoulder’ (it hurts and I can’t move it properly) and what a musculoskeletal specialist means by ‘frozen shoulder’ (very specifically, adhesive capsulitis) … and differentiating between the two is very important as they can have very different treatments and outcomes.

The shoulder is the most complicated joint in the body – in fact, it’s not one joint at all, it’s three joints plus the articulation between the shoulder blade and the top seven ribs.  If it’s going to work properly, there are over 100 joints, muscles, ligaments and bursae that have to we working normally and integrate smoothly.  Fortunately, of all the things that can go wrong, frozen shoulder (or adhesive capsulitis as we should call it from now on) is one of the less common.

Gardening without the pain

The gardening season has started and, all over Britain, hundreds of chiropractors are rubbing their hands in glee as thousands of gardeners beat a hasty path to their doors to remove the pain from their shoulders, the ache from their backs and the cricks in their necks… but it needn’t be like that.

There is a myth that things need to hurt after a day in the garden, so accepted by gardeners and physicians alike that nobody bothers to do anything about it other than suffer in silence, reach for the pain killers or give up gardening – which is a shame because gardening is not just good for the soul but can be an excellence source of exercise, fresh air and sunlight, if done right.

Sciatica is not the only condition that’s a pain in the ar•e

Sciatic pain is a common presentation to any chiropractic clinic and one of the commonest complications of low back pain… but, for every ten patients who think they have sciatica, probably only two or three actually do.

Part of the problem is that sciatica is used in everyday terms to describe pretty much any pain that runs down the leg; however, to a back specialist, such as a chiropractor, it refers very specifically to pain that arises from the sciatic nerve or its branches and it has a very specific pattern of distribution: down the buttock and the back of the thigh, often into the back of the calf and the sole of the foot. If it’s down the side or the front of your leg, then it’s not sciatica – but don’t worry, a chiropractor can probably tell you what it is !

Even if it is running down the back of your leg, sciatica still isn’t a definite diagnosis as sciatica isn’t the only thing that can cause pain in the back of your leg. Identical symptoms can arise from the ligaments, joints, muscles and bones in your spine or buttock – in much the same way that pain from the heart refers to your left arm in angina.

I’ve been told I’ve got … Migraines

I’ve been told I’ve got … Migraines.

One of the commonest medical presentations is headaches, and the consultation often opens “I think I’ve got migraines” … but when is a migraine not a migraine? 

To Begin at the Beginning…

…This, reflecting perhaps my unchanging enjoyment of Dylan Thomas, was the title of the very first editorial I ever wrote, 18 years ago, as the newly appointed editor of the equally new British Journal of Chiropractic (http://tiny.cc/gillox), which congratulated the profession within the UK for its commonality of educational and professional aims and standards and welcomed the immanent arrival of the General Chiropractic Council with chiropractic taking its place in the pantheon of regulated healthcare professions!

Ironically, the theme for my first professional blog is taken from the very last editorial I wrote.  By then, the journal had become international under its new identity Clinical Chiropractic and my ‘Fond Farewell’ took a few well-aimed swipes both at chiropractic bloggers, and the profession’s self-appointed, mostly unqualified detractors (http://tiny.cc/nvllox) who unsurprisingly feed gleefully off the rabid, misspelt ravings of the few in order to give credence to their own prejudicial misconceptions.