complicated case

Hi to all of you,

I am a young physiotherapist and I d like to share with you a case that I am having some months now. Apparentely the right diagnosis is not made yet so every treatment we have tried doesnt have the expected outcomes. I thought that by posting here I could have some more suggestions for what else to look for.

The patient is a woman 19y.o. She was a track and field athlete but she had to stop 4 years ago due to tendinopathy of both achilles and a partial rupture of the right one. She has taken physiotherapies for this ( ultrasound, tens, biofeedback, strengthening exercises) but always had short time effects. 1 year ago a leg length discrepancy was found with the right being 1.5cm longer. special inlayers are provided. the patient complains that carriability of her has decreased dramatically to the point that half an hour walking or just 10min of standing gives pain to the back that radiates to the whole both legs. Trigger points were found in piriformis, glut. med. , glut max as well as errector spinae. Hypomobility of sacroiliac joint exists. Manipulation of lumbar and thoracic spine is difficult and not firm. A huge contracture of the errector spinae is present. We gave her a rehab programme with strengthening, stretching and coordination exercises as well as running at home. We tried myofascial release techniques that seemed to help but really slow.We changed to dry needling so as to have faster effects and after the 2 first days she was complaining for severe attacks of back pain and tigling and numbness in the groin. Lasted 2-3 days and then relaxation came. 2 weeks after she was complaining for pain all over the legs and hypertonicity was present in lower extremity. In addition there are muscle twiches present quite often. All reflexes were absolutely fine. That make me think more the musculature but is really more forcefull than I expect.

Good day to you, my name's Nigel Bondswell and i have been a physiotherapist since 1996 reaching the dizzy height of Clinical Specialist within the NHS (what ever that means now). I presently work privately for my self and for a professional rugby league side called Keighley Cougars.

It is difficult to get a full understanding of a case through someone else with yourself assessing the person, even so i am willing to try and give you some possible tips on where to go.

Firstly in my opinion i think there has been to much emphasis,or over reliance on treatments such as electro therapy and other none hands on modalities which strictly speaking considering the gold standard of experimentation are poorly proven.

Have the tendinosis at the right and left Achilles tendons been sorted including strengthening of the right calf muscle to 5/5 on the oxford scale?

This should be tackled i think possibly looking at:
[LIST][*]deep friction massage[*]ice massage till numb carried out three times for one treatment[*]connective tissue manipulation for the calf muscle then[*]deep tissue mobilisation to the calf muscle[*]followed by stretching of the calf muscles perform several types to hit the variety of muscles in the calf
[LIST]

Yes there is debate due to the poor blood supply to the achillies tendon weather it should be deep frictioned or not, however i suggest considering the ice massage increased blood flow with increased oxygen will be delivered to the frictioned area so it is a viable treatment.

I. will come back with the rest of my suggestion when i have time. But look to the sacrum that is where the trouble lies i think.

Are the athlete's

have you considered the foot-ankle biomechanics and posture ? Is the cancaneum in valgus or varum and is the forefoot supinated or pronated. I would start there and do a thorough assessment of the foot posture. Any corrections can be made with Vasyl orthotics. Ensure gradual introduction of the orthotic over a couple of days i.e. half hour on and 3/4ths of an hour off until the orthotic is on full-time, then trial this intervention for say 2 weeks to see if the patients symptoms improve. Whatever malalignment occurs in the foot-ankle complex will be translated up the kinetic chain. Best to investigate from distal to proximal in this case. Just my opinion though. Good luck. (from a seasoned outpatient Aussie Physio working in America)

Quote:

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Originally Posted by TANIA van MD

Hi to all of you,

I am a young physiotherapist and I d like to share with you a case that I am having some months now. Apparentely the right diagnosis is not made yet so every treatment we have tried doesnt have the expected outcomes. I thought that by posting here I could have some more suggestions for what else to look for.

The patient is a woman 19y.o. She was a track and field athlete but she had to stop 4 years ago due to tendinopathy of both achilles and a partial rupture of the right one. She has taken physiotherapies for this ( ultrasound, tens, biofeedback, strengthening exercises) but always had short time effects. 1 year ago a leg length discrepancy was found with the right being 1.5cm longer. special inlayers are provided. the patient complains that carriability of her has decreased dramatically to the point that half an hour walking or just 10min of standing gives pain to the back that radiates to the whole both legs. Trigger points were found in piriformis, glut. med. , glut max as well as errector spinae. Hypomobility of sacroiliac joint exists. Manipulation of lumbar and thoracic spine is difficult and not firm. A huge contracture of the errector spinae is present. We gave her a rehab programme with strengthening, stretching and coordination exercises as well as running at home. We tried myofascial release techniques that seemed to help but really slow.We changed to dry needling so as to have faster effects and after the 2 first days she was complaining for severe attacks of back pain and tigling and numbness in the groin. Lasted 2-3 days and then relaxation came. 2 weeks after she was complaining for pain all over the legs and hypertonicity was present in lower extremity. In addition there are muscle twiches present quite often. All reflexes were absolutely fine. That make me think more the musculature but is really more forcefull than I expect.

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Determine if leg length deficiency is actual or apparent, then heel lift on short side. Start off with 1 cm heel lift and increase to 1.5cm. Make sure lift is comfortable as 1-1.5 cm may be a shock to the body. Start with thin lift if required and increase to comfort. If apparent deficiency then manipulation to pelvis and spine and re-measure. Dr. A.A.Fares

Hi Tanya Van MD...

I think you are actually right and that the muscle reaction is more forceful than you would expect.

I believe that they are working so hard because something else is driving the problem.

You say that hypomobility of the SIJ exists...how do you assess this?

You also say that manipulation is difficult and not firm - what do you mean by this?

In my opinion, focusing on the lower leg symptoms are not going to solve your problems but i think you already know this...have you assessed every joint from the foot up? I think this is where you should be now - test each joint in the foot to the ankle then the knee, hip, SIJ, each L/S joint, each costovertebral and costotransverse and T/S joint. You are looking to see if they are doing their job properly. It will take time but i think you need to be thorough and work through her problem systematically and logically.

Let us know how it goes :)

Hi Tania continuing from where i left of yesterday.

I said i would look to the sacrum, specifically the sacroiliac joints on either side of it and ensure there are enabling nutation and counter nutation of the sacrum, i.e. the sacrum is moving equally between the two sacroiliac joints (SIJ). The patient should be able to flex forward in standing with equal movement of the SIJ. Please do not get caught up in which way the sacrum is tilted and or moving if the SIJ's of the patient are not moving equally, which i think they are not considering the hypo mobility of one of the SIJ. This i think is due to the tight or shortened musculature you have already identified.

Although suggesting specific muscles i think is not always a good thing as muscles always work in combination with others. But for now looking at piriformis, gluts, tfl, erectae spinae, quadratus lumborum, hamstrings and qaudriceps all on the hypo mobile side of the SIJ would benefit from deep tissue mobilization then PNF stretches (hold relax stretches or muscle energy techniques as they liked to be called now a days).

Try posterior anterior mobilisations to the base and apex of the sacrum, has the nutation counter nutation of the sacrum increased?

Reassess?

Possibly simple rotation mobilization into a grade 4 post the muscle mobs may benefit the patient to?

Check patients leg length discrepancy pre and post treatment.

The tingling and numbness in the groin are symptoms of SIJ syndrome, in combination with the leg length discrepancy and hypomobility of the sij that's the working diagnosis i have come up with considering the information i have read and i have not assessed your patient.

Tania get your hands on this patient, the lower limbs posterior and anterior and the whole of the back musculature need mobilizing and stretching i think desperately i think.

Then see what you have to work on, as i see it,i t could be 1) Achilles tendinopathy 2)partial Achilles rupture 3) leg length discrepancy is that due to SIJ hpomobility 4)hypomobility at sij or SIJ syndrome causing "carriability" issues

If these are the major issues why do you need to prioritise is what i would be thinking.

And Tania we are physiotherapists our skill is in our hands..... please use them more before we loose our specialism.

Thank you in advance if you have read this reply.