Physiotherapy on Sport Injury Id#

Physiotherapy on Sport Injury

ID# Case Management

Case Management Assignment

In this essay thought to be best evidence-based practices for tendinopathy of the Achilles tendon. Tendinopathy has been reported as one of the most common injuries encountered in sports and in the workplace (Woo, Renstrom, & Arnoczky, 2007).tendinopathy is the inability of the Achilles tendon to return to its homeostatic balance. Researchers have gone further to explain that effective treatment can be difficult and depends somewhat on the person giving therapy and treatment. Woo, Renstrom, & Arnoczky, (2007 ) discuss that tendinopathy is a major medical problem associated with sports and physical activity in active people over 25 years of age. They define it as a syndrome of tendon pain, localized tenderness, and swelling that impairs performance. This is diagnosed through taking a history of the patient, though it is also explained that there are no definitive correlations made between history and symptoms.

The Achilles tendon is the single tendon of the soleus and gastrocnemius muscles, inserting into the calcaneum. It has a highly structured peritendinous tissue with no synovial membrane. The blood supply to the tendon enters on the deep (anterior) surface, and appears to be similar in volume throughout its length (Beeton, 2003).

Houglum (2010) defines tendinopathy as an irritation of the tendon that is displayed as pain, swelling, and reduced function. Unless visualized in surgery, the precise structure involved is difficult to determine. The Achilles tendon (AT) is the largest and most powerful tendon in the body. It can be involved in a number of pathological conditions, and often represent the sole manifestation of an underlying ailment. The etiology, pathogenesis, and natural course of AT pathologies are largely unknown, and current management modalities vary considerably depending from the etiological factors. AT pathologies have been associated with a multitude of disorders, such as inflammatory and autoimmune conditions, genetically determined collagen abnormalities, infectious diseases, and neurological conditions . AT is frequently involved in rheumatic disorders, although its clinical recognition is often under-reported (Ames, Longo, Denaro & Maffulli 2008). It is estimated that Achilles tendonitis accounts for around 11% of all running injuries. ("Achilles Tendinitis ( Tendinopathy) what is Achilles Tendonitis?," 2010, p. 1)

Achilles tendinitis is a common problem that affects the ankle. The Achilles tendon, which attaches the calf muscles to the foot, is a thick, ropelike structure that can easily be felt just above the heel. When the tendon becomes degenerated or inflamed, it can cause pain in the back of the ankle; in some cases, it can severely limit the patient's mobility. In the most severe cases (when the tendon is very degenerated), it may lead to Achilles tendon rupture, which generally requires surgery for athletic individuals. Achilles tendinitis often occurs in patients who have tight calf muscles. When the gastrocnemius and soleus are tight, increased stress is placed on the Achilles tendon, which can lead to the onset of symptoms. Achilles tendinitis is also associated with overuse attributed to sports that require running or explosive activity (Robert, n.d)

Currently, there is lack of consensus on the best management of acute Achilles tendon ruptures. Management can be broadly classified into operative open or percutaneous and non-operative cast immobilization or functional bracing (Ebinesan, Sarai, Walley, & Maffulli 2008). Recovery time appears contingent upon the method used for repair as well as the length of time and practices associated with post op treatment. Muscle strain is the term used for a moderate amount of soft-tissue damage to muscle fibers, usually caused by sudden, strenuous movements. Limited bleeding inside the muscle causes tenderness and swelling, which may be accompanied by painful spasms or contractions. Visible bruising may follow. More serious damage, involving a larger number of torn or ruptured fibers, is called a muscle tear. A torn muscle causes severe pain and swelling. Following a medical check to gauge severity, the usual treatment is rest, anti-inflammatory medication, and perhaps physiotherapy. Rarely, surgery may be needed to repair a muscle that has been badly torn. The risk of muscle strains and tears can be reduced by warming-up adequately before exercise (Muscle and Tendon Disorders, n.d.).

Search Strategy: To determine what literature was relevant in this case study key words were utilized during the search.

Key words included, Achilles tendon surgery, post Operations Management, treatment, possible procedures, current methods of treatment, physiotherapy, sports injury and treatments, injury rehabilitation, and diagnosis and prerequisites for treatment. After EBSCO, BJSM, Medline, Cochrane Database, CINAHL Plus, ProQuest, PubMed, Health Source, and Academic Search Elite. A Google Scholar search was conducted, significant information was located regarding Achilles tendonopathy, however, there were no resources that appeared to relate specifically to the post-op treatment of tendonopathy, nor did they appear to address my case (a 28-year-old male suffering from Achilles tendonopathy). Exclusions occurred regarding research for several reasons, first there were articles that though they did discuss tendonopathy the content did not relate to the 28-year-old subject in this case study, secondly, some research and information was more than 15 years old, which in itself did not prove to be an up-to-date nor a reliable source for a current study. Cost was also an issue as there were articles that could have had pertinent information, but were not assessable due to cost restraint issues.

Etiology and Pathophysiology

Ajis, Maffulli, Alfredson, & Almekinders (2010), explain that in the past two to three decades, the incidents of Achilles tendinopathy has increased due to an increase in participation in sports both recreational and competitive. An increase in the reports of Achilles tendon injures by runners has more than doubled. The incidence of Achilles tendinopathy in top-level runners is estimated at around 7-9%. Tendon injuries can fall into two categories, acute or chronic; and the cause can be intrinsic or extrinsic factors. Woo, Renstrom, & Arnoczky,( 2007) explain that chronic tendinopathy includes an increased degree of degeneration with or without inflammation present. Age plays a significant role in the severity of this injury. Tendinopathy can be caused by an interaction of extrinsic factors including training errors, such as excessive distance, intensity, hill work etc. Environmental issues can also play a factor i.e. cold weather. In addition, footwear and equipment may also play a factor in Achilles tendinopathy.

Cook & Khan (2007) explain that understanding the etiology of tendinopathy is a critical aspect of improving knowledge in this area, as it would allow active intervention in athletes prior to the onset of debilitating symptoms or tendon rupture. The cause on tendinopathy is unknown at this time. Peers (2003) reports that Achilles tendinopathy typically presents as exercise induced pain 2 to 6 centimeters proximal to the tendon insertion. Pain most often occurs at the beginning and after exercise. When the pathology progresses, pain will continue during exercise and may interfere with daily activities. Patients with tendonopathy will usually complain of stiffness in the morning.

Hammer (2007) conducted research regarding the etiology of tendinopathy, he explains that overuse injuries can create excessive loading of tissue, especially when it is associated with extrinsic factors, such as biomedical faults and mal-alignments, such as hyperpronation, as in Achilles tendinopathy. As stated in other research hammer confirms that the pathology of tendinopathy is unclear at this time. Houglum (2010) discusses that tendinopathy can occur as a traumatic or an overused condition. The three prevalent theories regarding tendinopathy are a mechanical theory, vascular, and neural.

Case presentation and decision for Post-Operations Management of Achilles tendon

Narrative: Marco, a 28-year-old athlete ( hurdler) complained of pain in the area of his Achilles tendon and lower calf during a running exercise at practice. At the time of injury it was decided that there was evidence of a possible Achilles tendonitis. Immediate evidence was not given as to if this was acute or chronic at the time of initial assessment on the field. No initial assessment was made regarding the location of the injury i.e. At the attachment point to the heel or in the mid-portion of the tendon. It was concluded that Marco would need to have further assessment as well as a health history interview in order to determine the problem and possible treatments. Onsite cold therapy was applied to the area on the right leg.

Assessment was conducted on Marco; he was asked a series of questions regarding the injury and previous pains or issues associated with the affected area. Marco reported that that he has had gradual onset of pain over the past several weeks, on a scale of one to five, five being every time, one being seldom to never, Marco reported that he has had pain with all physical activities and exercises. He mentioned that there was a slight sharp pain in the area of the Achilles tendon while walking and running. Pain was assessed to occur in the morning and during times of rest. Lumps were evident in the area of the Achilles tendon; constant tenderness in the area of injury was also evident. Swelling has occurred over the Achilles tendon. No redness was evident in the area of the injury.

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 curative. At this point, or on occasion earlier in the workup, an MRI is indicated. As in the case with Marco, an MRI will be necessary in order to determine and affirm the previous diagnosis.

Treatment for Suspected Rupture or tendinopathy (Maffulli & Almekinders; Woo, Renstrom, & Arnoczky, 2007; Beeton, 2003).

Controlled motion & exercise

Research if surgery is necessary

Patient is placed in an equines plaster of Paris cast

Referred to a weekly central TA rupture clinic ( patients will be seen between one and two weeks after rupture

Cast will be removed and the patient will be assessed

Physical therapy

Surgical management

Corticosteroid injections

Plenty of rest

Houglum (2010) divides treatment into five Phases:

1. Restoration of flexibility

2. Muscle endurance

3. Strength

4. Agility

5. Functional performance

Observations of a patient with a recent TA rupture presents: (Maffulli & Almekinders, 2007)

Classical bruising on both medial and lateral sides of the heel

The site of injury is not tender

There is no presentation of bony tenderness about the ankle

The tendon is examined

With tenderness over the Achilles tendon and a palpable gap ( affirms diagnosis)

The absence of plantar-flexion on calf squeeze adds further reassurance to this diagnosis.

After Diagnosis of the rupture ( Maffulli & Almekinders, 2007)

A suitably padded synthetic cast is applied with sufficient plantar-flexion to achieve satisfactory apposition of the tendon ends as per the clinical assessment

Prospective Management (Maffulli & Almekinders, 2007)

The skin wound is dressed w / gauze

A cast w / ankle plantigrade is applied.

Patient is discharged the same day of surgery

Advise patient to put weight on the affected leg

Must also have periods of elevation for the leg ( for 2 weeks)

After 2 weeks the cast is removed

A synthetic below knee slab is used ( Velcro straps) used for 4 weeks

Use of a physiotherapist

6 weeks post op (Maffulli & Almekinders,2007)

Anterior slab is removed

Stationary cycling and swimming therapy utilized

Allowed to train (gentle)

Patient is reviewed at 3, 6 and 9 months post op

Common causes of Achilles tendinitis (Disease/Disorder overview n.d.):

Overuse or overtraining. Achilles tendinitis can be caused by training or working out too much after not exercising for a while. It can be caused by adding too much time or distance to your athletic training. It may be caused by doing any activities that put stress (force or pressure) on the Achilles tendon. These include running uphill, jumping, or sprinting more than you usually do. These also include running or exercising on hard surfaces such as asphalt or cement.

Poor fitting shoes. Poor fitting shoes can cause uneven movement of your foot and heel in the shoe. This includes shoes with worn out treads, and shoes that do not provide good heel support. Shoes that are too tight or small can rub and irritate the Achilles tendon. Shoes that are stiff and cannot bend where the toes join the foot can also put stress on your Achilles tendon.

The way you walk or run. Your foot may roll inward too much when you walk or run. This is called overpronation. You may have high arches or may exercise in a way that puts stress on your Achilles tendon.

Tight tendons and muscles. You may have tight hamstring and calf muscles in your upper and lower leg. Your Achilles tendon may be tight, thick, and unable to stretch very well. Your tendons become stiffer and easier to injure, as you get older.

Arthritis. Bony growths caused by arthritis, especially around the heel, can irritate the Achilles tendon.

What are the signs and symptoms of Achilles tendinitis? You may have pain and tenderness over the tendon where it hooks to the heel. You may have redness and swelling over your Achilles tendon. You may feel stiffness, especially in the morning or after periods of rest.

You may first feel pain when beginning to run or exercise. The pain usually goes away as your muscles warm up, but it may come back after exercising.

Over time, if you do not rest your tendon and give it time to heal, the pain can get worse. You may have pain while exercising and even when you are resting. This may lead to small tears or a rupture (complete tear) of your Achilles tendon.

If your tendon ruptures, you may feel sharp pain in the back of your heel. You may hear a "pop" and feel like the back of your heel was hit very hard. You may have pain and difficulty when trying to walk or move your ankle.

How to Reduce the Risk of Complications

As with any other surgical procedure, complications do occur. In the case of any Achilles surgery, wound complications are most observed. Wound infections are always of concern. Gentle tissue dissection and meticulous paratenon closure are critical to safeguard against this occurrence. The majority of these types of cases involve patients who are functionally debilitated as opposed to high-caliber athletes ("Achilles Tendinitis (Tendinopathy) what is Achilles Tendonitis?" 2010, para. 10).

Physiotheripeutical management of Marco

In regards to the research available regarding Achilles tendonitis; an anti-inflammatory medication akin to Motrin or ibuprofen, taping of the back of the leg to support the tendon, Possible use of a plaster cast or boot depending on the severity of the injury. Use ultrasound treatment applied to the affected area. Utilize sports massage; prescribe a rehabilitation program to utilize regarding treatment. Assess possible utilization of steroid injections into the tendon, and scan with MRI. Surgery may be necessary if these methods are not affective.

The most common symptom is pain in the back of the heel or in the lower calf. The pain is usually worse in the morning because patients typically sleep with their toes pointed. When patients wake and put their feet on the floor, they stretch the Achilles tendons that have been in a relaxed position all night, and this produces pain. The condition is also aggravated with running or explosive exercises, including certain lifts such as variations of the Olympic lifts and calf raises. When the condition is very severe, patients can experience pain even with walking. Physical therapy is necessary and important. The most important aspect is stretching the gastro-cnemius with the knee straight and the soleus, with the knee slightly bent. Strengthening exercises, ultrasound, and electrical stimulation can also be used in physical therapy. Anti-inflammatory medication may speed recovery. Orthotics with a slight heel lift is sometimes used to relax the tension on the tendon. A night splint to keep the ankle at neutral flexion (90 degrees) could help by preventing tightness in the calf. In severe cases, a walking cast may be required to eliminate tension on the tendon (Marx & Stoppani, 2005).

Peers (2003) discuss the use of corticosteroids by first explaining that this is a therapy under extreme debate. Studies have shown short-term pain relief. The long-term effects of corticosteroids use appears to be less favorable than other physiotherapies available. Ice applications may be used for its analgesic effects and possible vasoconstrictory effect on the neovascularisation within tendinosis. Beeton, (2003) explains that rest as a treatment for tendinopathy stems from the previous inflammatory paradigm of tendinitis, and will be effective in reducing pain, but offers no improvement into musculotendinous function. Beeton also discusses the utilization of conservative treatment as exercise-based program is essential in tendon rehabilitation, appropriate and progressive exercise must be prescribed if rehabilitation is to succeed. Inadequate amounts of load, speed, and endurance may result in incomplete rehabilitation.

First physiotherapy session, post injury:

When Marco first arrived for treatment, he was asked about pain management, and what he had been doing at home for care of the Achilles tendonitis.

Goals post injury: Continue therapy and pain management. Continue weekly sports massage, cold therapy, and insure that boot is being worn regularly.

RX;

Explanation of the characteristics of Achilles tendonitis and what activities can aggravate the injury

Provide information regarding length of therapy, and anticipated percentage of recovery ( reassessment after 10 consecutive weeks of wearing therapeutic boot and other necessary therapies)