511 Achilles Tendinopathy

Preparation Period

The Problems your Treatment will Address

Pain and inflammation over Achilles area
Foot orthotics
Bio mechanics

Goals of Treatment:

The overall objective is to return patient to normal functional activities with no return of symptoms when performing sport and other outdoor activities.
Decrease swelling, pain and inhibition
Address misalignment of foot (over pronation with supinated forefoot on affected L side)previous plantar fascia problem
Aid tendon healing

Therapeutic goals of Friction:
The pressure of the stroke increases circulation to the deep fascia and ms tissue
Breaks up fascial adhesions and scar tissue
Seperates the different components within the ms and aids in fibre relaignment
Mechano – receptor stimulation (reduction in pain due to anti nociceptive process)

Therapeutic goals of Ultrasound:
Thermal effects of US may include
increased blood flow, reduced ms spasm, increased extensibility of collagen fibres and a pro inflammatory response. Thermal effects can be achieved with elevation of tissue temp of 40-45 deg/ C for at least 5 mins. The remodelling process can take up to 1 year. US can influence the remodelling of scar tissue by enhancing the orientation of the newly formed collagen fibres and changing the collagen profile from a type 3 to a type 1 construction – increasing the tensile strength and enhancing the scar mobility. In this way US is said to increase the overall functional capacity of scar tissue.

Altered cell membrane function
Mast cell degranulation
Stimulation of fibroblast activity
Increased protein synthesis
Increase intra cellular Ca levels
Increase vascular permeability
Increase angio genesis
Increase tensile strength of collagen


Chosen treatment and Dose

measure: goniometer measure of hamstring ROM
deep tissue friction massage - 3 x 5 minutes sessions
US: The lesion is superficial so 3MHz
The lesion is chronic so 0.5 W/cm.sq
There is no need to increase surface dose to allow for loss of US dept
Time : 1min * number of times treatment head fits over lesion* pulse ratio = 1* 4* 2 = 8 mins
Final treatment dose 3MHz; 0.5W/cm.sq; Pulsed 1:1; 4mins

The key Evidence that Supports your Chosen Treatments:

1.
Watson, T. (2008)
‘Ultrasound in contemporary physiotherapy practice’ 48 (4), pp. 321-329
Science Directe [Online]. Available: http://www.sciencedirect.com/science/article/pii/S0041624X0800036X

Watson
(2008) found that US during the remodelling process of tissue repair can
increase the overall functional capacity of scar tissue

2.
Maffulli, N.,
Sharma, P. and Lascombe, l. (2004) ‘Achilles Tendinopathy: aetiology and
management’ 97, pp. 472-476 Ebsco [Online].
Available at: http://ejscontent.ebsco.com/ContentServer

Maffulli, Sharma and Lascombe (2004) found that frictional massage
in chronic cases should be accompanied by stretching to restore tissue
elasticity and reduce the strain on the muscle tendon unit with joint motion.

Treatment Demonstration

1. Introduce yourself

2. Explanation of signs, symptoms, problems and goals of treatment:

Signs & Symptoms

The Achilles tendon is the name of the thick fibrous band that attaches the calf muscle, or the gastrocnemius muscle, to the heel bone. It is one of the thickest tendons in the body beginning about half way up the post lower leg. It is 15cm long and inserts into the middle posterior surface of the calcaneus. A bursa between the two. When the calf muscle contracts, it shortens and pulls
on the Achilles tendon. This action results in pushing the foot downward. We use our Achilles tendon in this manner when pushing off during walking, running, and jumping. This action of the Achilles is also what we use to walk on our tip toes. Due to the amount of strain that we put on our Achilles tendon during activity, it is especially susceptible to injury. The most common conditions experienced are Achilles tendon ruptures and Achilles tendonitis. chronic Achilles tendonitis is common in older athletes who are generally active gradual onset of pain at the back of the ankle, over a period of weeks or even months which is typical in this case in your case pain at the onset of exercise which is relieved by rest pain in the tendon when walking especially uphill or stairs there may be nodules or lumps in the tendon (2-4 cm above insert) pain on palpation swelling or thickness over the tendon, which may also be red over area

Problems

Pain and inflammation over Achilles area
New foot wear could be a contributing factor
Ankle bio mechanics (over pronation with L foot with supinated forefoot ) is putting stress on the tendon causing excessive overload resulting in trauma

Goals

The overall objective is to return you to normal functional activities with no
aggravation of symptoms when performing sport and other outdoor activities
Decrease swelling, pain and inhibition Address misalignment of foot (over pronation with supinated forefoot on affected L side) Aid tendon healing

3. Explanation of the proposed treatment session; therapists/ pt role:

The treatment session will include deep transverse frictional massage followed by therapeutic ultrasound. Frictional massage is quite a rigorus technique. I will apply a strong pressure to the exact symptomatic area working in a cross sectional motion. The massage will likely temporarily make the pain worse, but in the long run it will decrease pain and inflammation by breaking
up the scar tissue and adhesion formation. This will help realign the tendon fibres and promote the natural healing process.Therapeutic ultrasound will help speed up the healing process by bringing the condition back to a pro inflammatory phase. Tiny invisible sound waves will penetrate tissue; some are absorbed and some are reflected. The absorbed waves contain energy which stimulates the healing process. Ultrasound is painless on application, but a pro- inflammatory response can induce pain.

4. Consent

5. Contra-
Indications

Deep
frictional massage:
Bacterial inflammation
Arthritis
Ossification of soft tissues
Bursitis
Pressure on nerves
Local skin lesions






Ultrasound:
Malignancy
Tissue integrity
Vascular problems eg. Dvt
Infection
Bony prominence

Precautions US
Pregnancy
Cardiac area in heart disease
Epiphyseal plates
Spinal cord after laminectomy
Anaesthetic areas
Cranium, eyes, gonads, prosthesis,
stellate ganglion

6. Establish a
baseline using an objective marker:

Observation of gait pattern i.e stance
phase on left leg is a little shorter than the right with no push off
Pain on Passive ROM (dorsiflex 20 deg)
VAS for pain scale

7. Specific
Safety Checks:
For US a thermal sensation test must be
carried out before the treatment commences. This is to ensure the patient can
feel pain if the machine is operating at fault
No safety checks of frictional massage
Patient allergies for gel

8. Treatment
Deep
Friction
Deep fibre friction is applied without
any slip on the skin, so little or no lubricant
The tendon must be stretched so foot in
neutral dorsiflexion
Technique need to be applied directly
over lesion (middle 1/3 of L tendon)
Work Transverse to fibres
You need to know attachments of soft
tissue and fibre direction *anatomy NB.
Counter irritant so you are using the
scar tissue to rub off itself
Start gently and gradually build up
pressure
Support foot in dorsiflexion, hold
Achilles tendon with thumb on one side, whilst on the other scoop the tendon in
a supinated motion with middle finger over index finger technique




Ultrasound
Machine settings – 4 things you need to
change on the machine – frequency, pulsing, power and time
Machine
frequency – dept of the lesion to be treated (less than 2cm) Machine
set 3MHz – this is because the target tissue is within 2cm of the skin surface.
3MHz is absorbed more rapidly in the tissues, and is more appropriate for
superficial lesions
Pulse
ratio: determines the concentration of energy. So for
a 1:1 ratio; means one unit of
ultrasound followed by one unit of rest. The machine is operating at a 50% duty
cycle. The more acute the tissue state is, the more energy sensitive it is, and
responds better to a larger pulse ratio eg. 1:4 (lower duty cycle)
1:1 or continuous for chronic conditions
1:2 and 1:1 for subacute
1:4 to 1:3 for acute
Intensity: as with
ratio, intensity of US will vary with tissue state. The more acute the lesion
the less strong US needs to be to achieve tissue excitement. The more chronic
is less sensitive and requires greater intensity to achieve a physiological
response.
0.2 – 0.8 W/cm.sq for chronic
0.2 -0.5 for subacute
0.1 – 0.3 acute
½
life and dose calculation
The lesion is superficial so 3MHz
The lesion is chronic so 0.5 W/cm.sq
There is no need to increase surface
dose to allow for loss of US dept
Time : 1min *
number of times treatment head fits over lesion* pulse ratio = 1* 4* 2 = 8 mins
Final treatment dose
3MHz;
0.5W/cm.sq; Pulsed 1:1; 4mins

For chronic condition the patient should
be warned that tissue will be brought back to an acute phase before healing
will occur. This may exacerbate symptoms
‘they will get worse before better’. A pro inflammatory effect can induce pain.

9. Recheck Objective
Marker:
Observation
of gait pattern i.e stance phase on left leg is a little shorter than the right
with no push off
Pain on
Passive ROM (dorsiflex 20 deg)




10. Explain expected effects and outcome of treatment:

The pressure of the stroke increases
circulation to the deep fascia and ms
tissue
Breaks up fascial adhesions and scar
tissue
Seperates the different components
within the ms
Mechano – receptor stimulation
(reduction in pain due to anti nociceptive process)

Thermal effects of US may include
increased blood flow, reduced ms spasm, increased extensibility of collagen
fibres and a pro inflammatory response.
The remodelling process can take up to 1
year. US can influence the remodelling of scar tissue by enhancing the
orientation of the newly formed collagen fibres and changing the collagen
profile from a type 3 to a type 1 construction – increasing the tensile
strength and enhancing the scar mobility. In this way US is said to increase
the overall functional capacity of scar tissue



11. Post treatment advice to maintain or facilitate
improvement:
So I would like to see the patient trying to
get back no normal activity as soon as possible. It is important to load the
tendon so the natural healing process
occurs, but too much stress will make the symptoms worse. Balance is key. I
would like to see the patient walking 1 mile, and if able go further. I don’t
want to see any running the first week. If symptoms improve, after the second
week we may think about a light jog, but we will monitor the condition closely.
Think about new foot wear
Stretching exercise to increase ROM and
improve elongation of Gastroenemius and Soleus
Eccentric ms training and strength