Posts in Foot and Ankle Injuries
How Heavy Should I Load My Achilles Tendon After An Overuse Injury?
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In the achilles tendinopathy (artist formally known as tendonitis) research two main themes have emerged. First, there is little to no evidence to support the use of injections of any kind into an injured tendon. Authors have advocated against steroid injections due to the risk of tendon rupture outweighing any potential benefits. Studies have also been limited in the use of PRP (platelet rich plasma) injections for tendon pain. Significant methodological concerns have impacted this area of research including the lack of large human trials, lack of placebo or alternative treatment (exercise) comparison, and small sample sizes. Without improvements in this line of research, PRP remains an expensive, experimental treatment compared to other proven treatment strategies.

Strengthening exercises remain the gold standard of care, both in the research and our Boulder Physical Therapy practice, for these tendon injuries. Although eccentric exercise was first published in the late 1990s as an effective treatment for tendinopathy, many other forms of strength training including isometric and isotonic exercise have also been shown to be effective. The key take home message from these trials remains the same, injured tendons must be progressively loaded based on their clinical presentation to recover. Initially improvements in a patient’s symptoms and function are secondary to improved strength of the surrounding muscles while long term improvements are attributed to structural healing of the tendon (remodeling).

A recent review of the evidence highlights the importance of intensity or resistance during achilles strength training exercises for patients with mid portion achilles tendinopathy (Murphy et al. Br J Sp Med. 2019). Authors reviewed the available literature on the use of heavy eccentric training for this patient population compared to a wait and see or traditional Physical Therapy approach (modalities, massage). They reviewed the data from 7 studies and reported heavy eccentric training may be superior to a wait and see approach and traditional Physical Therapy. Authors also found a trend showing these heavy eccentric exercises may be less effective than other forms of exercise (isometric, isotonic).

This review is consistent with our current understanding on tendon management. Tendons should be progressively loaded based on the tendon’s tissue tolerance and irritability. Although eccentric exercise has become popular, other forms of exercise and loading strategies should also be considered as part of the tendon loading plan of care. When it comes to tendons, one size does not fit all.

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Is There An Additive Effect of Ultrasound to Physical Therapy Care?
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Few things remind me of how far we have come as a profession than ultrasound. Early in my career we utilized ultrasound and other modalities to help reduce a patients pain. Initially touted as a medium to deep tissue heating and healing, ultrasound has now fallen out of favor due to the lack of research benefits supporting its’ use. Little to no research supports its’ use for musculoskeletal conditions and any benefits have not been found superior to comparable placebo treatments. For these reasons we do not utilize or own an ultrasound machine in our Physical Therapy practice and instead utilize more evidence based interventions such as manual therapy and exercise for musculoskeletal conditions. A recent article examined if there was any additional benefit of ultrasound when combined with other Physical Therapy interventions.

A randomized controlled trial in the Journal of Orthopedic and Sports Physical Therapy examined the addition of either ultrasound or placebo ultrasound to a stretching program for patients with heel pain (Katzap et al. 2018). 54 patients were randomized to one of the ultrasound conditions combined with ankle and foot stretching exercises (note: stretching alone does not constitute an evidence based exercise program). Authors reported both groups improved but no significant differences were found between “therapeutic” ultrasound and placebo ultrasound. Authors recommended excluding ultrasound from treatment plans for patients with heel pain.

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Achilles Tendon Injury Treatments
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A recent clinical practice guideline was published advising clinicians and patients on the management of achilles tendon injury (tendinopathy).  These guidelines are based on both the available medical research and medical opinions from experts in the field.  The Journal of Orthopedic and Sports Physical Therapy reported the following for management of mid portion achilles tendinopathy (Martin et al. 2018).

Grade A - Strong Evidence

Exercise - Exercise utilizes progressive loading of the injured tendon and promotes tendon healing or remodeling.  This process occurs through mechanotransduction and creates a stronger, healthier, and more resilient achilles tendon.  Evidence supports the use of both eccentric exercise or a heavy load concentric and eccentric exercise prescription.  Conversely, complete rest is not recommended due to its' negative effects on the healing process.

Grade B -  Moderate Evidence

Activity Modification - As we stated above, complete rest of an injured tendon often leads to delayed or incomplete healing of the injured tissue.  A tendon has limited blood supply and metabolism compared to other body tissues requiring exercise to facilitate the healing process.  A progressive, goldilocks approach is recommended because doing too little is just as harmful as doing too much.  As your tissue heals and becomes resilient to a certain level of activity, the load and exercise volume is increased slowly to promote further healing in the tendon.  This process is continued until you return to 100%.  Injured tendons can take up to 1 year to completely heal at the tissue level and patients are advised to continue to exercise even after resolution of their symptoms, usually around 12-16 weeks.

Grade C - Weak Evidence

A lack of ankle bending or dorsiflexion is a commonly found risk factor and corresponding impairment in patients with achilles tendinopathy.  Stretching of the calf and plantar flexors is commonly prescribed in patients with tendinopathy but the supporting evidence for this stretching is weak.  We commonly recommend utilizing strength training within the ankle's available range of motion instead of static stretching.  Recent evidence suggests eccentric strengthening is equally effective to static stretching for mobility. 

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Further research is needed regarding other commonly utilized achilles tendinopathy including manual therapy.  In our Boulder Physical Therapy practice we find the utilization of joint manipulation, mobilization, and dry needling to be very effective in the short term for reducing pain and improving patient function.  These passive interventions are quickly withdrawn as patient's begin to load their injured achilles tendon tissue.  

 

Conflicting evidence was found for utilization of heels lifts or orthotics in the management of this condition.  We do not recommend these inserts in our practice due to their short term, limited effectiveness and potential for creating long term problems including joint tightness and muscle weakness.  

 

 

Does Manual Therapy Improve Plantar Fasciitis?
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Plantar fasciitis (fasciosis) is a painful diagnosis limiting a patient's ability to stand, walk, or run.  The -itis of the name is a misnomer because very few cases of plantar heel pain involve an inflammatory process.  Instead, a breakdown of soft tissue fibers and cells is noted in the plantar fascia reflecting the sequential stages of healing.  Contributing factors to this diagnosis include a loss of ankle mobility, calf muscle tightness, and foot weakness.  In our Boulder Physical Therapy practice we successfully treat this condition with the combination of exercise and manual therapy treatments designed to rapidly reduce and improve range of motion in the foot and ankle.  

A recent review of the available literature on the utilization of manual therapy for patients with heel pain was conducted (Fraser, J. et al. J Man Manip Ther. 2018).  Authors included 7 previous randomized, controlled trials on the utilization of this treatment in patients with plantar fasciitis.  They reported a significant short (4 weeks) and long term (6 month) improvement in patient function when Physical Therapists included manual therapy into their treatment sessions.  The authors recommended clinicians utilize both joint and soft tissue treatments, in addition to, high level exercise when treating patients with plantar fasciitis.  

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No Additional Benefit Of Orthotics Over Shoes Alone
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We have previous discussed the limitations of orthotics to control lower extremity alignment.  Another common reason for orthotic use is to control the degree of pronation or flattening of the foot during foot strike in walking and running.  The theory believes orthotics are able to impact force absorption by controlling this motion at the foot and ankle joints.  Much of this theory is based off an "ideal" neutral position of the foot and ankle called subtalar neutral.  The research into subtalar neutral is conflicting and this position may not be optimal for either static or dynamic foot function.

A recent article in the Medicine and Science in Sport and Exercise journal examined asymptomatic participants with flat feet.  These participants were given custom orthotics based on the sub talar neutral theory.  Each participant then walked at a preferred and fast speed under 3 conditions: barefoot, athletic shoe, and athletic shoe plus orthotic.  Authors measured force and EMG data during each condition.  Results demonstrated the effects of reduced pronation and energy absorption were similar between shoe and shoe and orthotic conditions indicating no further benefit of orthotic use.  Authors reported the benefits of reduced pronation (flattening) and force transmission were due to primarily to shoe wear. 

Increased Ankle Stiffness Reduces Proprioception and Balance
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Injuries to our spinal and extremity joints can impact a variety of structures including muscle, ligament, and nervous system receptors.  The sensors or proprioceptors are critical in providing real time feedback to our spinal cord and brain on the positions of our limbs.  This feedback system is disrupted by injury leading to slower information processing and in turn a loss of balance.  Most commonly this cascade is seen in patients with ankle sprain.  Without balance training and physical therapy our proprioceptive system remains impaired.

A recent study in the Journal of Orthopedic and Sports Physical Therapy (Rocha Marinho, H. et al. 2017) examined the proprioceptive and balance abilities of patients complaining of ankle joint instability and their uninjured peers.  The authors also evaluated the passive movement in the subjects ankles.  Consistent with previous research the patients complaining of ankle instability demonstrated the worst proprioception or balance.  Those with limited ankle mobility and higher levels of stiffness demonstrated reduced balance or proprioceptive ability.  This research highlights the importance of retraining the nervous system after joint and muscle injury.  
For more information on proprioception training contact your local Physical Therapist.