Clinic Experience Tuesday 5th November 2019 – 3 hours

Patient 1 – This appointment was a 15minute ultrasound session. A new system has recently been introduced whereby patients are able to book a 15minute appointment to cover ultrasound only. The idea behind this stems from the suggestion that therapeutic ultrasound is more effective when repeated in close succession of each treatments, as opposed to previously recognised recommendations such as three times a week or less. For example, a study on tendon-bone healing on rabbits found that low intensity pulsed ultrasound was more effective when administered twice a day compared with once a day (Lu et al., 2006).
The reason for allowing this ultrasound specific appointment time as an option is to give patients a better chance to fully adhere to the most efficient treatment as this option is not only quickly but more cost effective; instead of having to book a standard one hour appointment at full price, shortened ones are available without the additional consultation element which is unnecessary if the sessions are so close together.
Frustratingly the previous therapist had not left any information about the dosage for this patient, so the session was not as efficient as it could have been. It would have been good practice to talk with the patient to confirm treatment and check progress but I felt that the missing information caused a slight delay, especially as there was no available supervisor to consult with. However, I used my knowledge on ultrasound and applied it to this individual injury based on a quick subjective and previous treatment notes.
This patient had chronic achillies tendinosis in both achillies tendons and the dosage was as follows:
– Pulse Ratio = Continuous
– Time = 3 minutes as size of the area was approximately 3 treatment heads and pulse ratio continuous.
– Depth of lesion = 3MHz
Intensity = 0.8W/cm2

Within my clinic revision notes, I have created a help sheet with the calculation chart for easy access throughout clinic. The following chart is a reference provided by Watson (2017):

I have found it difficult to find research proving evidence for the use of therapeutic ultrasound on soft tissue injuries, but there is a body of evidence that questions the clinical efficacy of its use and has found it to be ineffective in musculoskeletal injuries.
An early review by Speed (2001) discussed that although ultrasound does have physiological effects on soft tissue, such as increased blood flow, increased tissue temperature, decreased muscular spasms, increase in muscle extensibility and also an enhancement of the inflammatory process of tissue healing, there is little evidence in support of this modality in a clinical setting and in the treatment of injured tissues. The use of this treatment is therefore difficult to justify. Furthermore, there have been studies to show that ultrasound treatment is of little value in the treatment of soft tissue injuries, including blunt contusions or injuries to the lower limbs (Shanks et al., 2010; Wilkin et al., 2004).
Interestingly, however, it has been suggested that therapeutic ultrasound, specifically pulsed and of low intensity, may be effective in the treatment of bone fracture healing, as it has been found to contribute to up to 38% in the reduction of bone fracture healing times (Warden, 2003).
Although therapeutic ultrasound has been found to be effective in a study by Ng et al. (2003) on enhancing achillies tendon strength in rats, at present, the most commonly cited research for the effectiveness of therapeutic ultrasound for musculoskeletal injuries in humans is Watson (2008) and as this is over ten years old, it is clear that more research needs to be conducted in order to provide good evidence, if available, to fully support the use of this treatment to treat soft tissue injuries.

Patient 2 – During this clinic session, it quickly became apparent that one of my follow up patients had arrived for her appointment, but was not booked into the online system. It was clearly a clinic error as the patient had retained the booking card but there were no therapists available. In the absence of the clinic supervisor on this occasion, it was important that we remained professional and managed the error as efficiently as possible, so that no patients were affected.
As I had a short 15minute ultrasound (U/S) session first, I had hoped to quickly work through this appointment and squeeze in this patient and hastily accepted responsibility for treating the extra patient. However, I had not fully thought it through and underestimated the time it would take me to perform ultrasound. Although the U/S patient was very understanding and had even suggested that he rebook his appointment, I wanted to ensure that he received the best possible care that we could provide; rescheduling his appointment would defeat the object of the regular U/S treatments.
Because the previous therapist did not specify the dosage of U/S, it took me a little longer to treat as I had to conduct a more thorough assessment to allow for accurate dose calculations and I therefore felt rushed, which the patient would undoubtedly have noticed.
By overrunning the first appointment, all of my subsequent patients were made to wait for almost 30mins after the start of their original appointment time, which I was very unhappy about. Although I tried to do my best by everyone in this occasion, it may be more appropriate and less impactive if in the future we accept the mistake and deal with the extra patient more specifically, explaining the situation, apologising and offering a future appointment free of charge or at a reduced rate.
Fortunately, all patients who were affected by this mistake were happy to help in the situation by their patience and understanding.
This session was a follow up soft tissue massage (STM) of the neck and shoulders, for a patient who returns on a weekly basis.

Patient 3 – Insertional Achillies Tendinopathy
Patient Overview: Recently diagnosed and is being treated for breast cancer; has been given the all clear. Onset of heel pain while receiving radiotherapy treatment, has not improved and would like to start running to get fit.
The onset of pain was severe and the result of maintaining a painful position of the foot while undergoing radiotherapy for breast cancer; the heel was compressed within the patient’s shoe while the foot was being forced into inversion with the knee internally rotated and foot elevated so that the tibia and fibular of the talocrural joint glided posteriorly, a similar movement to that of the anterior drawer test.
As compression of the insertion site of the achillies tendon to the calcaneal bone is a recognised cause of this injury (Bah et al., 2016) I was able to identify a possible tendinopathy initially based on the subjective assessment.

Due to the late start of this treatment as a result of the aforementioned appointment mix up and due to the patient not being in the correct attire, I decided not to perform STM on this occasion. I would have hoped to start the treatment with some STM to help lengthen the Triceps Surae muscle group as a way to manage symptoms of tension and any tightness in the gastrocnemius and soleus muscles (Stefansson et al., 2019) as any tightness here may contribute to the compression and irritation of the achillies tendon. Exercise and rehabilitation programs for achillies tendinopathies have been widely reported, however not for the more specifically characterised insertional tendinopathy. Kedia et al. (2014) conducted a randomised clinical trial, providing subjects with a 12-week exercise regime for stretching the gastrocnemius, soleus and hamstrings, concluding this an effective method of treatment. The addition of widely used eccentric exercises interestingly, showed no additional benefits. This implies that, whether cause or effect, the triceps surae muscle group tightness could be treated by whatever effective means to lengthen and relieve tightness and be used as an objective measures of ankle dorsiflexion by gastrocnemius stretching, such as the knee to wall; a test reportedly of good reliability (Stefansson et al., 2019).
It would have been the best practice in this scenario to perform the knee to wall test to measure the tightness in the patient’s lower limb and compare bilaterally, not only to identify a possible causes of injury but as an objective measure of the effectiveness of treatment. However, I had forgotten to use an objective measure on this occasion. It is very important that l add this to all treatments as a mandatory element within the session. In order to remind myself to use clinical measures, I will add a section in my consultation form as a simple reminder and build up a repertoire of measures for different areas of treatment.
The patient reported the sensation of her ankles feeling “wooden” at the start of any activity or after waking in the morning and loading the joints. Findings from Bah et al. (2016) highlight the mechanical differences between the achillies tendon with and without insertional achillies tendinopathy, showing significant differences in tissue and recommending a controlled dorsiflexion routine before physical activity as a way to reduce tendinopathy associated pain. The knee to wall test is used to assess ankle dorsiflexion ROM and is a good indicator of muscular tightness in the gastrocnemius and soleus as well as any associated or isolated joint stiffness and has good evidence to suggest consistency and repeatability, reported in a review by Powden et al. (2015). In any subsequent sessions, I will be able to use this as a way of measuring any progress in symptoms and aim to enhance the patient’s ankle ROM and morning symptoms when first moving her feet.

References –

Bah, I., Kwak, S. T., Chimenti, R. L., Richards, M. S., Ketz, J. P., Samuel Flemister, A., & Buckley, M. R. (2016). Mechanical changes in the Achilles tendon due to insertional Achilles tendinopathy. Journal of the Mechanical Behavior of Biomedical Materials. https://doi.org/10.1016/j.jmbbm.2015.08.022

Kedia, M., Williams, M., Jain, L., Barron, M., Bird, N., Blackwell, B., … Murphy, G. A. (2014). The effects of conventional physical therapy and eccentric strengthening for insertional achilles tendinopathy. International Journal of Sports Physical Therapy.

Lu, H., Qin, L., Fok, P., Cheung, W., Lee, K., Guo, X., … Leung, K. (2006). Low-intensity pulsed ultrasound accelerates bone-tendon junction healing: A partial patellectomy model in rabbits. American Journal of Sports Medicine. https://doi.org/10.1177/0363546506286788

Ng, C. O. Y., Ng, G. Y. F., See, E. K. N., & Leung, M. C. P. (2003). Therapeutic ultrasound improves strength of achilles tendon repair in rats. Ultrasound in Medicine and Biology. https://doi.org/10.1016/S0301-5629(03)01018-4

Powden, C. J., Hoch, J. M., & Hoch, M. C. (2015). Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review. Manual Therapy. https://doi.org/10.1016/j.math.2015.01.004

Shanks, P., Curran, M., Fletcher, P., & Thompson, R. (2010). The effectiveness of therapeutic ultrasound for musculoskeletal conditions of the lower limb: A literature review. Foot. https://doi.org/10.1016/j.foot.2010.09.006

Speed, C. A. (2001). Therapeutic ultrasound in soft tissue lesions. Rheumatology. https://doi.org/10.1093/rheumatology/40.12.1331

Stefansson, S. H., Brandsson, S., Langberg, H., & Arnason, A. (2019). Using Pressure Massage for Achilles Tendinopathy: A Single-Blind, Randomized Controlled Trial Comparing a Novel Treatment Versus an Eccentric Exercise Protocol. Orthopaedic Journal of Sports Medicine, 7(3), 1–10. https://doi.org/10.1177/2325967119834284

Warden, S. J. (2003). A new direction for ultrasound therapy in sports medicine. Sports Medicine. https://doi.org/10.2165/00007256-200333020-00002

Watson, T. (2008). Ultrasound in contemporary physiotherapy practice. Ultrasonics. https://doi.org/10.1016/j.ultras.2008.02.004

Wilkin, L. D., Merrick, M. A., Kirby, T. E., & Devor, S. T. (2004). Influence of Therapeutic Ultrasound on Skeletal Muscle Regeneration Following Blunt Contusion. International Journal of Sports Medicine. https://doi.org/10.1055/s-2003-45234

 

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