As part of 2016 Allied Health Series we will talking to allied health professionals about how they would approach a particular condition (Achilles Tendinopathy). This is to highlight to similarities and differences between allied health professionals in an Evidence Based Medicine Society.
Achilles Tendinopathy Case Study
AGE: 54years old
BMI = 22
L/Mid Portion Achilles pain which has been present for approximately 4months.
Recently a grandmother (3months) and baby sits 4 times a week.
Pain described as an ache most of the time with occasional sharp grab.
VAS: 6/10 most of the time, 9/10 at worst, 2/10 at best
Walk/Jog x3 weekly
Pump Class x3 weekly
Swimming x1 weekly
No further information has been collected.
What is your qualification?
BAppSc (Exercise Science/Human Movement);
BHlthSc (Clinical Myotherapy)
Specialised or unique case history approach
Some further questioning that may be asked during the initial screen and questioning may include, how long it has been since flying, if at all in the last 4 months? Is there any pain anywhere else? If so, is it higher or lower of the mid portion Achilles pain. The exercise that she is doing may be contributing to her issue, continuing to probe for how she exercises including what sort of walking she does (power walking or leisurely ) and what sorts of movements are undertaken in the pump class may reveal how the initial injury progressed to a tendinopathy.
Continuing on from this looking at regions higher and lower than the affected area may be necessary. This may include looking at the feet to look for signs of extra wear including blisters or sores. Knees and hips should be screened also to ensure that the source of the problem is not coming from another of region of the body.
Lastly looking at her footwear for signs of wear. This may give an indication of over pronation in her walking stride and a referral to a podiatrist may be necessary.
Specialised or unique assessment procedures
While the patient still has their shoes on I would get them to undertake a number of movements including calf raises, toe taps and walking up and down a step. On removing the shoes standing from behind may reveal some over-pronation. You may also notice higher in the kinetic chain bowed Achilles tendons or internal knee rotation. When performing a dorsiflexion lunge test you would be expecting a score lower than 7cm from the wall due to the thickening and decreased range of movement.
With the patient in a prone position on the table I would begin to feel around the area of the Achilles. Feeling through the Gastrocnemius and Soleus gives me an indication of the integrity of the muscles. In most cases you would suspect a lot of tightness with limited dorsiflexion. As you progress lower in the Achilles tendon itself I would be feeling for a thickening of the tendon with limited lateral or medial movement. While holding the foot in dorsiflexion resisted movement into plantarflexion would create tenderness and pain for the patient.
Specialised or unique equipment for assessment and treatment
Hot packs and heated gels can be used when trying to heat the Gastrocnemius and Soleus muscles to increase blood flow, while cold therapies can be used to reduce inflammation. Although this may not be as effective as the tendon is now in the degenerative phase which is characterised by collagen degeneration and cell death.
Dry needling may be another modality that we may use. Dry needling can alleviate major trigger points within the muscle bellies of Gastrocnemius and Soleus. These tight areas in the muscle may be causing it to be tight leaving it with limited range of motion, being ineffective in its pull on the tendon and weak. Furthermore like the heat therapies the needles bring blood flow to the area to increase waste products being removed.
Stretching like the other therapies already mentioned, increases blood flow to the area. The other important benefit to stretching is increasing the muscle spindles metabolism, increasing the uptake of oxygen into the muscle therefore creating a relaxed muscle. Stretching also causes an overall increase in range of movement due to the stretch on tissues.
When takin the patient through take home exercises, the eccentric loading exercises would have to be the one of choice. This strengthens the tendon through increase motor behaviour increased cellular activity and hypertrophy of the musculotendinous junction.
Specialised or unique treatment types/approaches
Treatment targets and criteria for prognosis, referral and management outcomes
Reduce pain is our main objective when treating a patient with an Achilles tendinopathy. When someone is pain free they are better able to participate in everyday activities. Increased range of movement can be measured also for the patient to get a sense of achievement and increase motivation. This would done through the weight-bearing dorsiflexion-lunge test. As the pain decreases and the range of movement increases an increase in pre-injury exercise activities can be achieved with management of load.
Referral to a podiatrist for closer examination of foot biomechanics would be advised and also some form of orthotic may be helpful in making a full recovery. Furthermore referral to an exercise physiologist may be advised to strengthen the lower limb.