To design a management plan you need to:
- Have completed a comprehensive assessment
- Have agreed patient goals
- Have developed physiotherapy aims
- Know the clinical efficacy of treatments (EBP)
- Be able to rationalise management
Have measurable outcomes to evaluate effectiveness
Characteristics of tendon pain
localised
provoked by loading –> more loading = more pain
latency period –> 24 h behaviour
Mismatch in load vs capacity: too much load for tendon to handle (training error)
Patella tendinopathy common in which age group
16-20 year olds
Most common upper and lower limb tendinopathy
Most common lower limb tendinopathy = gluteal
Most common upper limb = rotator cuff tendinopathy
Gluteal tendinopathy common in which demographic and why
Gluteal tendinopathy common in post menopausal women - drop in estrogen (good for tendon health and synthesis of collagen) causes tendon problems
What makes a good outcome measure/questionnaire?
- Easy to interpret
- Specific
- Validity: test should be related to the disease
Responsive: changes as patients get better
How might we come to the diagnosis of achilles tendinopathy?
Pain with activity
Increase in training volume
Insidious onset of pain, no mechanism
Well localised
Heavy slow loading vs eccentric only exercises for treating Achilles Tendinopathy
- Both strategies improve pain and function (Murphy MC, 2019)
- Little difference b/w VISA-A scores
- Traditional eccentric program (Alfredson’s) more time consuming (300 + mins per week) –> compliance?
- Little scientific evidence for isolating the eccentric component
–> why not do both? - Magnitude load effects tendon adaptation – not contraction type
- HSL – better compliance, but requires gym equipment
Advice and education for Achilles tendinopathy
- Activity modification is essential
○ Relative rest/modify activity - management of the patient’s tendon load - first decrease load to control symptoms and then increase load to improve tendon capacity- Pain monitoring (Silbernagel 2007)
○ Traffic light system - pain levels up to 5/10 - Evidence exists that continuing running with acceptable levels of pain (<5/10) in the presence on Achilles tendinopathy does not adversely effect outcome. - No residual pain within 24h
- No exacerbation after
- How much and for how long is guided by irritability
- Pain monitoring (Silbernagel 2007)
Is manual therapy useful of achilles tendinopathy
- Not an important player
- Little use/efficacy
- Likely short term effect for pain soft tissue massage to triceps surae
- Can use clinical reasoning to address impairments – but must be alongside a progressive rehabilitation program for the achilles tendon and kinetic chain
- Little use/efficacy
Exercise program for achilles tendinopathy
Stage 1
- Isometrics
To reduce pain
No compression
Calf Raise Holds
Stage 2
- Strength
o Muscle/kinetic chain strength
o Functional strength
o Strength endurance
o No compression
Double leg into single leg calf raises
Seated calf raises into weighted
Stage 3
- Energy storage
o Faster
o End of range eccentric
Add compression
* Fast calf raises
* Jumping
* Box Jumps
Stage 4
- Energy storage and release
o Sports specific loading
o Compression
Functional Strength Exercise
Speed
Change in Direction
Stage 5
- Get rid of all stage 4 exercises and replace directly with stage 5 exercises
- Exercises need to be sport specific
- Return to run program… ensure is walking first pain free (use 10%, only run 2 x per week initially, walk/run program)
Difference in insertional achilles tendinopathy
pain with activities involving DF
Modification for insertional achilles tendinopathy
Key modification is heel inserts in shoes, no dorsiflexion during loading exercises (no eccentrics, go into neutral only)
Management plan for insertional achilles tendinopathy
- Management plan: Modifying ADL to remove dorsiflexion where practical. Wear high heels or heel raised shoes. Don’t walk without shoes. If wanting to walk, walk on flat surface. When rehab do on neural position
- No stretching of the calf
Which condition is commonly misdiagnosed as a lateral ankle ligament injury
talar dome fracture
Are braces useful for reducing risk of reinjuring ankle sprain
Yes - better than exercise for recurrent sprains but not for first time sprain
Education for ankle sprain
- Discuss prognosis - clinical course
o First episode; benign problem, don’t worry too much
o Sometimes, it takes time (25%-50% > 3 months) - Risk of CAI
o Advice to stay active
o Avoid immobilization
o Introduce movement as soon as possible - Discuss goals & management options
- Graded exposure to movement in ADLs
Difference in people with chronic ankle instability and people who just sprain ankle once or never have sprained ankle
Found people who continue to keep spraining their ankle (CAI) vs people who just sprain once or had never sprained (controlled) land differently at heel strike (more laterally)
How can we potentially help those with chronic ankle instability that land more laterally
- Encourage to shift centre of pressure medially as required (“Push through centre of foot or push through your big toe”) when performing exercises
Management plan for ankle sprain
Decrease pain and swelling
Increase ROM, strength, weight bearing
Strength/proprioception training
What does an AP glide of the talocrural joint do?
Increase DF
What does an PA glide of the talocrural joint do?
Increase PF
What does a subtalar joint transverse mobilisation do?
increases pronation/supination
Pronation: calcaneal eversion, ABD, DF
Supination: calcaneal inversion, ADD, PF
What does a talocrural joint distraction do?
increased general ankle ROM
