Day 13 – Sports Therapy and Rehabilitation Clinic

Duration: 5 hours  Cumulative hours: 136.40

Reflection in Action (as it happens)

I didn’t have any appointments scheduled for the morning but I shadowed one of my peers during a F2F appointment with a patient with suspected insertional Achilles tendinopathy.

Patient 1

The patient explained the history of his injury so that I could get an idea of the stage of tendinopathy.  We established that it was at the degenerative stage as the patient had been managing the injury for 9 months (Cook & Purdam, 2009).  The patient used to run but had stopped due to the injury.  He had increased walking during the UK Lockdown which may have contributed to the overload resulting in the insertional tendinopathy.  He also had an ACL injury about 8-10 years ago but he did not seek treatment or rehabilitation because as a self-employed professional he could not afford the time required for the rehab post ACL-reconstruction.

The objective examination revealed a lump on the lateral side of the heel on the left leg.  The patient did not display any strength deficits in the hamstring muscles in resisted prone knee extension.  The knee to wall test revealed restricted dorsiflexion in both ankles (7 degrees on the left and 8 degrees on the right).  He also had reduced ROM.  During walking the patient turned out his right foot, which demonstrated a change in gait as a result of compensation due to the reduced dorsiflexion.  I measured the ankle with the goniometer but I wasn’t sure whether I executed the technique correctly.  Static dorsiflexion during the knee to wall test was 20⁰ on the right leg and 32⁰ on the left leg.  Normative range for static dorsiflexion during the knee to wall test is 33⁰-39⁰.  There was a reduction in dorsiflexion on the right leg and left leg.

The patient was completed a VISA-A form and the score was 55/100 which indicated.  The Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire has been shown to be a reliable and robust outcome measure to assess the severity of AT before and after treatment (Iversen, Bartels, & Langberg, 2012; Robinson et al., 2001).  Patients with AT will usually have a VISA-A score below 60 and a VISA-A score of above 90 indicates that the patient is ready to return to training.

The patient was prescribed home-based exercises following an eccentric loading protocol and banded exercises for the quadriceps and hamstrings to strengthen up the upper limb muscles and prevent the patient from externally rotating his right foot.

Patient 2

I met patient 2 during an online triage appointment when she booked an appointment for treatment for acute lower back pain.  We carried out a full subjective assessment and our clinical impression at the time was that the patient was experiencing pain as a result of an intervertebral disc bulge impinging on the sciatic nerve.  The patient returned to the clinic during the earlier part of the following week and saw another therapist.  The therapist treated the patient for sacroiliac joint dysfunction after carrying out a full objective assessment.  I was a bit surprised at how they arrived at the conclusion that the patient’s pain was due to sacroilliac joint dysfunction.  If the patient was in acute pain, the battery of special tests that they carried out would aggravate the pain in either condition and the results of the tests would therefore be positive.  I discussed it with my clinical supervisor who read the notes.  She was of a similar opinion.

The patient walked into clinic without any visible signs of pain.  She reported that the home-based exercises prescribed during her previous appointment had helped and she was experiencing less pain, which was very positive.  We said that she still experienced pain during movements in flexion, lifting heavy objects.  Rotation movements of the body were much less painful.

After carrying out the objective assessment we were still of the opinion that there was a lumbar discogenic bulge at approximately L$/L5 with slight impingement of the sciatic nerve.  The treatment administered was repeated movements in prone lumbar extension with lateral hip shift to the right and left to establish which movement was less painful.  Repeated lumbar extension with lateral shift of the hip to the right side was less painful.  We retested the straight leg raise and observed an improvement of 10 degrees.  We therefore revised the home-based programme to include repeated movements in prone lumbar extension and the book under the bum exercise.

1. Pelvic tits – 2 sets of 5 reps
2. Eye through the needle – 2 sets of 5 reps
3. Lateral hip rotations – 3 x 20-30 second holds
4. Prone extension – 1 set of 10 repeated holds of 10 seconds with 10 second rest
5. Book under the bum exercise to be held as long as patient feels comfortable.

Reflection on Action (afterwards)

Patient 1

We had a discussion with the clinical supervisor about the use of ultrasound in the treatment of the patient’s tendinopathy to reduce pain.  I had a read of the literature and treatments recommended for tendinopathy are those that stimulate cell activity and encourage production of collagen to restructure the matrix (Cook & Purdam, 2009).  In vivo studies have documented the effectiveness of ultrasound treatment on tendons and have also demonstrated that ultrasound can promote migration, proliferation and collagen synthesis by tendon cells (Tsai, Tang, & Liang, 2011).

Extracorporeal Shock Wave Therapy has also been shown to improve Achilles tendinopathy (Zhang, Li, Yao, Hua, & Li, 2020).  In their review of the literature however Stania et al., (2019) concluded that factors such as the complexity of biological response to shock waves, the high diversity of application methodologies, and the lack of objective measures all prevent the effectiveness of ESWT for Achilles tendinopathy from being fully determined.  There are gaps in the literature yet to be researched and the results of experimental studies are contradictory.  The literature review however does show that ESWT is a safe treatment modality but there is a need for randomised control studies on the effectiveness of ESWT for Achilles tendinopathy.

Patient 2

I was glad of the advice and experience of my clinical supervisor during the objective assessment of the patient.  The results of the objective assessment confirmed our original assessment of the patient’s lower back pain.  It was very rewarding to see that the patient’s lower back pain has improved and the patient was very positive at the end of the examination.

References

Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416. https://doi.org/10.1136/bjsm.2008.051193

Iversen, J. V., Bartels, E. M., & Langberg, H. (2012). The victorian institute of sports assessment – achilles questionnaire (visa-a) – a reliable tool for measuring achilles tendinopathy. International Journal of Sports Physical Therapy, 7(1), 76–84. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22319681%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3273883

Robinson, J. M., Cook, J. L., Purdam, C., Visentini, P. J., Ross, J., Maffulli, N., … Khan, K. M. (2001). The VISA-A questionnaire: A valid and reliable index of the clinical severity of Achilles tendinopathy. British Journal of Sports Medicine, 35(5), 335–341. https://doi.org/10.1136/bjsm.35.5.335

Stania, M., Juras, G., Chmielewska, D., Polak, A., Kucio, C., & Król, P. (2019). Extracorporeal Shock Wave Therapy for Achilles Tendinopathy. BioMed Research International, 2019. https://doi.org/10.1155/2019/3086910

Tsai, W. C., Tang, S. F. T., & Liang, F. C. (2011). Effect of therapeutic ultrasound on tendons. American Journal of Physical Medicine and Rehabilitation, 90(12), 1068–1073. https://doi.org/10.1097/PHM.0b013e31821a70be

Zhang, S., Li, H., Yao, W., Hua, Y., & Li, Y. (2020). Therapeutic Response of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy Between Sports-Active and Nonsports-Active Patients With 5-Year Follow-up. Orthopaedic Journal of Sports Medicine, 8(1), 1–6. https://doi.org/10.1177/2325967119898118