The client reported no known history of Sever’s disease which is an apophysitis caused by pulling at the point of insertion of the Achilles Tendon into the calcaneus causing heel pain which has been reported in young athletes (D Reid 1992).
The site of pain was indicated with one finger to be two to three centimetres proximal to the insertion at the Calcaneus over the Achilles tendon. This was recorded against the anatomical picture.
Questioning the aetiology of the clients’ history of present complaint, the client reported a gradual onset of pain which worsened during physical training lessons. As a result was unable to continue the training programme. The course of action that lead the client to seek medical help and duration of time before treatment was established, this is important as the client may have seen a Doctor and received treatment or an x-ray for example (appendix 1).
Questioning the clients past and current activity levels the client reported that training intensity had increased over the last two to three weeks, with a mixture of loaded combat marches and cross country runs over varying terrain. The client reported the nature of the pain to be a mild stabbing, pricking pain with and after activity, which is symptomatic to Achilles tendon injury (Ljungqvist, R. 1968). Morning stiffness that improved with activity was also reported. With only two weeks remaining the client was keen to return to the training programme and would therefore require a high level of post injury fitness. Questioning the clients’ drug history (DH) the client was not taking any medication such as non-steroidal anti-inflammatory drugs (NSAIDs) which would invalidate the objective assessment. The client did not have any other known conditions associated with the current injury. The client did report feeling tired but generally keen and in good general health (GH).
Objective Assessment
The information obtained during the subjective assessment should guide the sports rehabilitators’ selection of objective tests, as well as the vigour with which they should be carried out.
The client was then suitably undressed for the objective assessment. This allows the practitioner to visually observe the client (appendix 1). Because of the clients’ age and sex a chaperone was offered but declined (appendix 1). The clients’ posture was generally poor. It was observed that the client had excessive bilateral pronation, with internal tibial rotation. This is an important observation because excessive pronation produces a whipping action in the Achilles tendon. The whipping action, may contribute to microtears in the tendon, particularly in the medial aspect, which may cause an inflammatory response (Clement et al, 1984). This action was observed during the clients’ gait, which confirmed excessive pronation.
Compared to the right the left Achilles was showing signs of inflammation with redness, evidence suggests this maybe related to morning stiffness as reported in the subjective assessment.
The active ranges of motion (AROM) of the ankle were tested in the supine position with the knee flexed and extended. The established normal range of movement as suggested by the American Academy of Orthopaedic Surgeons, 1965, during plantar flexion is 0 – 50◦ and dorsi flexion 0 – 20◦ it was observed that the left ankle had a reduced range of movement compared to the right, this was due to the clients’ pain however the right was also reduced from the normal AROM showing signs of possible bilateral gastrocnemius, tibialis anterior imbalance/tightness (appendix 1). The same movements were tested passively with light over pressure testing end range and end feel confirming a tight gastrocnemius compartment which in its self causes prolonged pronation of the foot (Williams 1986).
Tightness can increase the stress on the Achilles tendon, and a tendonitis can develop. The range of movement was no better with the knee flexed indicating soleus tightness also. Using the visual analogy scale (VAS) which is a tool widely used to measure pain; on the injured side the client indicated a point approximately four centimetres out of ten centimetres. Using the muscle grading test the right compared to the left was at a ratio of four to five respectively with pain indicating an obvious weakness (Kendall 1993).
With the presenting symptoms and clients discomfort no ligament tests or special tests such as the Thompson squeeze were deemed necessary (Thompson 1962). However palpation confirmed tenderness over the Achilles area with minor crepitus which was detected when moving the Achilles through its fullest range of movement. The area indicated receives its vascular supply predominantly through the paratendon; studies suggest that avascularity in this area may play a role in Achilles tendon disease (Clement et al, 1984). During palpation the client reported no altered sensation clearing dermatomes; this suggests no neurological pathology (appendix 1).
Functionally active resisted planter flexion was measured with the client standing on her toes, alternating between the injured and uninjured side. Flexing the knee eliminated Soleus muscle involvement. Active resisted dorsi flexion was measured by performing a squat which uses all the joints of the lower limb kinematic chain, eliminating the joints of the knee and hip of any underlying pathology. The quality of movement and symmetry was generally good with no referred pain clearing myotomes; this suggested no neurological pathology (appendix 1).
Examination of the clients’ footwear, noted that the client was wearing standard Army issue training shoes, which are cheap and of poor design. Logic dictates that poor footwear can be attributable to many lower limb disorders.
Analysis
The clinical impression gathered leads to a second degree Achilles Tendinitis disorder. Tendinitis is inflammation of the tendon. Thus, Achilles Tendinitis is an inflammation of the Achilles tendon. The primary symptoms were pain and inflammation localized to the back of the lower leg closer to the heel than to the muscles of the calf (appendix 1). Pain was reported upon contraction of the calf muscles effecting ROM and gait. The aetiology to its development is secondary to a multifactor of the clients training errors such as poor lower limb flexibility, poor footwear, sudden training intensity, terrain surfaces along with faulty lower limb biomechanics primarily pronation.
Plan
Conservative treatment is recommended initially with surgical exploration if unsuccessful (Densted 1979). The plan was broken down into short, intermediate and long term goals which where discussed and agreed with the client. Effective treatment required immediate withdrawal from all activities that induce symptoms. Crutch immobilization followed by gradual return to weight bearing activities. NSAIDs, could be taken according to directions which can be found in the British National Formulary 2000, along with ice treatment progressing to contrast baths and massage. Supplement normal training with swimming as it is non-weight bearing and allows for gentle motion of the feet at the ankle and weight training to minimize the decline in fitness. The client should wear well-designed and fitted footwear following gradual transition from one shoe to another. Correcting faulty foot biomechanics with prescribed orthotic devices which correct heel and forefoot misalignments and heel lifts to reduce strain on the tendon could be considered (Bates et al). The client will adhere to a consistent gradual training programme, without sudden changes in training intensities consisting of a daily program of lower leg mobility, strength training and flexibility exercises.
Treatment Strategy for
Achilles Tendininitis
Brief Summary
The SOAP notes format provided a systematic approach that allowed the Sports rehabilitator to assemble enough information through elimination to form a clinical impression, thus allowing both parties to formulate a treatment plan. It also was the start of professional relationship with the client.
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References:
- American Academy of Orthopaedic Surgeons (1965). Joint Motion: Method of measuring and recording.
- Bates, B.T, Osternig L.R, Mason B, and James L.S. (1979). Foot orthotic devices to modify selected aspects of lower extremity mechanics. Am. J. Sports Med.
- British National Formulary (2000). Published by the British Medical Association.
- Corrigan, B. & Maitland G (1994). Musculoskeletal & Sports Injuries: Butterworth-Heinemann Ltd.
- Clement D. B (1984). Achilles tendonitis and peritendinitis: Etiology and Treatment: The American Journal of Sports Medicine.
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Kendall FP, et al (1993). Muscle Testing and Function, 4th Ed. Baltimore. Williams and Wilkins.
- Ljungqvist, R (1968). Subcutaneous partial rupture of the Achilles tendon. Acta Orthop. Scand. Suppl.
- Thompson TC (1962). A test for rupture of the tendo-achilles. Acta Orthopaedica Scandinavinica.
- D Reid (1992). Sports injury assessment and rehabilitation: Churchill Livingstone.
- Williams J.G.P (1986). Achilles tendon lesions in sport. Sports Medicine.
- Mclatchie G.R & Lennox M.E (1996). The soft tissues trauma and sports injuries: Butterworth-Heinemann Ltd.
