Week 2

Question 1

To design a management plan you need to:

Answer 1

• Have completed a comprehensive assessment
  
  • Have agreed patient goals
  • Have developed physiotherapy aims
  • Know the clinical efficacy of treatments (EBP)
  • Be able to rationalise management
    Have measurable outcomes to evaluate effectiveness

Question 2

Characteristics of tendon pain

Answer 2

localised
provoked by loading –> more loading = more pain
latency period –> 24 h behaviour
Mismatch in load vs capacity: too much load for tendon to handle (training error)

Question 3

Patella tendinopathy common in which age group

Answer 3

16-20 year olds

Question 4

Most common upper and lower limb tendinopathy

Answer 4

Most common lower limb tendinopathy = gluteal
Most common upper limb = rotator cuff tendinopathy

Question 5

Gluteal tendinopathy common in which demographic and why

Answer 5

Gluteal tendinopathy common in post menopausal women - drop in estrogen (good for tendon health and synthesis of collagen) causes tendon problems

Question 6

What makes a good outcome measure/questionnaire?

Answer 6

• Easy to interpret
  
  • Specific
  • Validity: test should be related to the disease
    Responsive: changes as patients get better

Question 7

How might we come to the diagnosis of achilles tendinopathy?

Answer 7

Pain with activity
Increase in training volume
Insidious onset of pain, no mechanism
Well localised

Question 8

Heavy slow loading vs eccentric only exercises for treating Achilles Tendinopathy

Answer 8

• Both strategies improve pain and function (Murphy MC, 2019)
  
  • Little difference b/w VISA-A scores
  • Traditional eccentric program (Alfredson’s) more time consuming (300 + mins per week) –> compliance?
  • Little scientific evidence for isolating the eccentric component
    –> why not do both?
  • Magnitude load effects tendon adaptation – not contraction type
  • HSL – better compliance, but requires gym equipment

Question 9

Advice and education for Achilles tendinopathy

Answer 9

• Activity modification is essential
  ○ Relative rest/modify activity - management of the patient’s tendon load - first decrease load to control symptoms and then increase load to improve tendon capacity
  
  • Pain monitoring (Silbernagel 2007)
    ○ Traffic light system - pain levels up to 5/10 - Evidence exists that continuing running with acceptable levels of pain (<5/10) in the presence on Achilles tendinopathy does not adversely effect outcome.
  • No residual pain within 24h
  • No exacerbation after
  • How much and for how long is guided by irritability

Question 10

Is manual therapy useful of achilles tendinopathy

Answer 10

• Not an important player
  
  • Little use/efficacy
    
    • Likely short term effect for pain soft tissue massage to triceps surae
  • Can use clinical reasoning to address impairments – but must be alongside a progressive rehabilitation program for the achilles tendon and kinetic chain

Question 11

Exercise program for achilles tendinopathy

Answer 11

Stage 1
- Isometrics
To reduce pain
No compression
Calf Raise Holds

Stage 2
- Strength
o Muscle/kinetic chain strength
o Functional strength
o Strength endurance
o No compression
 Double leg into single leg calf raises
 Seated calf raises into weighted

Stage 3
- Energy storage
o Faster
o End of range eccentric
 Add compression
* Fast calf raises
* Jumping
* Box Jumps

Stage 4
- Energy storage and release
o Sports specific loading
o Compression
 Functional Strength Exercise
 Speed
 Change in Direction

Stage 5
- Get rid of all stage 4 exercises and replace directly with stage 5 exercises
- Exercises need to be sport specific
- Return to run program… ensure is walking first pain free (use 10%, only run 2 x per week initially, walk/run program)

Question 12

Difference in insertional achilles tendinopathy

Answer 12

pain with activities involving DF

Question 13

Modification for insertional achilles tendinopathy

Answer 13

Key modification is heel inserts in shoes, no dorsiflexion during loading exercises (no eccentrics, go into neutral only)

Question 14

Management plan for insertional achilles tendinopathy

Answer 14

• Management plan: Modifying ADL to remove dorsiflexion where practical. Wear high heels or heel raised shoes. Don’t walk without shoes. If wanting to walk, walk on flat surface. When rehab do on neural position
• No stretching of the calf

Question 15

Which condition is commonly misdiagnosed as a lateral ankle ligament injury

Answer 15

talar dome fracture

Question 16

Are braces useful for reducing risk of reinjuring ankle sprain

Answer 16

Yes - better than exercise for recurrent sprains but not for first time sprain

Question 17

Education for ankle sprain

Answer 17

• Discuss prognosis - clinical course
  o First episode; benign problem, don’t worry too much
  o Sometimes, it takes time (25%-50% > 3 months)
• Risk of CAI
  o Advice to stay active
  o Avoid immobilization
  o Introduce movement as soon as possible
• Discuss goals & management options
• Graded exposure to movement in ADLs

Question 18

Difference in people with chronic ankle instability and people who just sprain ankle once or never have sprained ankle

Answer 18

Found people who continue to keep spraining their ankle (CAI) vs people who just sprain once or had never sprained (controlled) land differently at heel strike (more laterally)

Question 19

How can we potentially help those with chronic ankle instability that land more laterally

Answer 19

• Encourage to shift centre of pressure medially as required (“Push through centre of foot or push through your big toe”) when performing exercises

Question 20

Management plan for ankle sprain

Answer 20

Decrease pain and swelling
Increase ROM, strength, weight bearing
Strength/proprioception training

Question 21

What does an AP glide of the talocrural joint do?

Answer 21

Increase DF

Question 22

What does an PA glide of the talocrural joint do?

Answer 22

Increase PF

Question 23

What does a subtalar joint transverse mobilisation do?

Answer 23

increases pronation/supination

Pronation: calcaneal eversion, ABD, DF

Supination: calcaneal inversion, ADD, PF

Question 24

What does a talocrural joint distraction do?

Answer 24

increased general ankle ROM

Question 25

What does a subtalar joint distraction do?

Answer 25

Increases general inversion/eversion

Question 26

What does a first MTP AP glide and distraction do?

Answer 26

Increase extension of first toe