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Supporting Research and Results
Maffulli & Almekinders (2010) conducted a comparable study on 140 patients with Achilles tendon ruptures. Treatment included a conservative protocol. Re-rupture rate using this protocol is maintained at 4%. Events of re-rupture were treated using the same conservative regime. A significant percentage of patents utilizing the conservative method were able to return to competitive athletic ability (i.e. their previous sporting level)
(Woo, Renstrom, & Arnoczky, 2007) The management of tendinopathy is often based on a trial and error basis. Use of a questionnaire asking about sport history may be useful. In contrast Beeton ( 2003) states that tendinopathy can be resistant to treatment, and symptoms may persist despite both conservative and surgical interventions. The pathology of overuse tendinopathy is non-inflammatory, with a degenerative or failed healing tendon response.
(Wasielewski & Kotsko 2007) Prolonged musculoskeletal stresses are necessary for the development of symptomatic tendinosis; as a result, certified athletic trainers are likely to see these disorders frequently. In 2003, the Bureau of Labor Statistics reported more than 11-000 cases of chronic tendon injury that resulted in days away from work in the United States. Sporting activities may impose even greater stresses on tendons than occupational activities. The prevalence of Achilles tendinosis has been estimated to be between 11% and 24% in runners, whereas the prevalence rates for patellar tendinosis in basketball and volleyball players have been recorded as high as 32% and 45%, respectively. These estimates clearly indicate that tendinosis is a very common problem.
Lower extremity tendinosis have proven difficult to manage. Symptomatic Achilles and patellar tendinosis may preclude participation in physical activity, prematurely terminate athletic careers, and structurally weaken the tendon to the point of rupture. Approximately 25% to 33% of athletes with lower extremity tendinosis demonstrate poor outcomes with conservative therapy, necessitating surgery; including all the surgical candidates, only 46% to 64% are able to return to sports after a recovery period of 6 to 12 months. Although the intensity of symptoms associated with tendinosis is greatest during periods of overuse, symptoms persist long after the end of an athletic career. The foundation of conservative management for lower extremity tendinosis has traditionally included cessation or reduction of the offending activity, therapeutic modalities, non-steroidal anti-inflammatory medication, and corticosteroid injections. Unfortunately, the effectiveness of these treatment modes is limited because they primarily focus on decreasing inflammation, which is absent in tendinosis. Limited clinical effectiveness has forced clinicians to look to alternate means of treatment, such as eccentric exercise (Wasielewski & Kotsko 2007).
The term tendinopathy has been used as a general clinical descriptor to indicate pain in the region of the tendon without any indication of the underlying cause. However, the prevalence of tendinopathies is apparently increasing. For example, in New Zealand the incidence of Achilles tendon ruptures more than doubled between the years 1998 to 2003, from 4.7/100,000 to 10.3/100,000, a phenomenon that follows international trends. Patella tendinopathy accounted for 20% of all knee injuries reported over a six-month period at a sports injury clinic, while tennis elbow affects approximately 1%-2% of the population. Other common sites of tendinopathy are golfer's elbow at the medial side of the elbow, and the rotator cuff tendons in the shoulder. Perhaps because of the multifactorial nature of the pathogenesis of tendinopathy, there is a plethora of treatment modalities available to reduce symptoms and to attempt to control or enhance the tendon healing response. These modalities, which include various electrotherapy modalities, eccentric exercise, a variety of injection techniques, and cross-fiber massage, provide mixed or uneven benefit across patient populations (Tumilty, Steve, et al. 2010)
Low-level laser therapy (LLLT) or the use of laser sources at powers too low to cause measurable temperature increases, has been used to treat soft tissue injuries and inflammation since the 1960s, and studies from as early as the 1980s reported benefits in a variety of tendon and sports injuries. More recently, the term LLLT has been used to describe not only the use of low power laser sources, but also monochromatic super luminous diodes. Both types of system have been used in the treatment of various musculoskeletal conditions, including tendon injuries, each apparently with success. Such applications are supported by experimental evidence of the biological effects of LLLT, including increased ATP production, enhanced cell function, and increased protein synthesis. LLLT has also been shown to have positive effects on the reduction of inflammation, increase of collagen synthesis, and angiogenesis. While LLLT is promoted as a safe and effective form of treatment for a variety of conditions, in today's healthcare climate there is a necessity to practice evidence-based medicine, and a need to provide high-level evidence to support the use of any treatment modality. Whether previous research into the effectiveness of LLLT has accomplished this is debatable due to the varying quality of the available research (Tumilty, Steve, et al. 2010)
Reasoning: Marco's presentation fits the characteristics of Achilles tendonopathy. Therefore, it is necessary to assess the best treatment for the tendonitis as well as follow-up treatment. In terms of general anatomic considerations, it is important to recall that the Achilles tendon is surrounded by a clear areolar tissue that allows movement between the tendon and the surrounding tissue. This paratenon is capable of manifesting an inflammatory response and can become adherent in conditions such as peritendinitis and/or tendinosis. Another significant consideration is that of the rotation of fibers as the tendon courses distally. The fibers externally rotate beginning approximately 12 to 15 cm from the insertion and reaching a maximum of 2 to 5 cm proximal to it. This rotation may give insight as to why this area of the tendon is notoriously afflicted with pathology. It may also give credence to the use of orthoses in the context of a reverted heel ( Blahous, 2006).
One final but significant anatomic consideration is the popular contention of a hypo vascular or so-called "watershed" region of the Achilles tendon. Tendinosis, by definition, is a degenerative process of the Achilles, which manifests with the clinical hallmark of fusiform swelling. The patient rarely recalls a traumatic injury or sentinel event to induce the symptoms. While post-static dyskinesia is prevalent, pain is often exacerbated with increased exercise. In my opinion, I have found that running is the primary inciting activity, which Marco was doing during the time of the injury. Clinical signs are often the aforementioned fusiform swelling and intratendinous nodularity. On occasion, swelling may be visible; however, Marco did not show significant signs of swelling at the site of injury. ("Achilles Tendinitis ( Tendinopathy) what is Achilles Tendonitis?," 2010, para. 6)
Treatment, again is customized for each patient as stated in this research and other research conducted. However, one can follow the same general protocol. Initially, relative rest is recommended considering the results that alone have been witnessed in reset and elevation alone.. Depending on the intensity of the symptoms and/or their duration, relative rest may range from boot immobilization to simple activity modification. Most patients require a boot for two to three weeks. Additionally, clinicians should encourage ice massage when Achilles tendinopathy is being assessed and treated. It is important to reiterate that tendinosis often does not respond to anti-inflammatory interventions (Blahous, 2006).
Subsequently, the patient will begin an organized, methodic, and specific 12-week physical rehabilitation program. Researchers are credited with characterizing the heavy load eccentric calf muscle training regimen that has truly revolutionized the treatment of Achilles tendinosis. It would behoove the practicing physician to obtain and understand this technique, as it truly is the cornerstone of the conservative treatment. Furthermore, it is important to have a close relationship with the physical therapist in order to perform the protocol correctly. While most will achieve adequate success without invasive treatment, some cases will invariably present no results or results that are not as positive as previous cases. Newer alternative therapies are continuously evolving with variable clinical success (Blahous, 2006).
Tan & Chan (2008) explain that Achilles tendinopathy usually manifests as pain in the mid-portion of the tendon, while patellar tendinopathy occurs as an enthesopathy near the patellar origin. Pain is usually reported with tendon loading at the beginning of exercise that subsides with continued activity but can progress to pain during activity requiring its cessation. Symptoms present for less than 2 weeks can be classified as acute, 2 -- 6 weeks as sub-acute, & longer than 6 weeks as chronic. There are 4 phases of patellar tendinopathy, which are applicable to other tendons: Pain only after activity; pain/discomfort during activity, but does not interfere with participation; pain both during and after participation, which interferes with competition, and complete tendon disruption.
If surgery is necessary, it is again imperative to rule out any other adjunctive pathology that may either coexist with tendinosis or may appear to be Achilles tendinopathy, and is clarified with further diagnostic investigation. Patients have reported profound pain with hyperplantarflexion of the ankle and the patient was ultimately diagnosed with a painful ostrigonum. Excision of the accessory bone was…[continue]
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