Christine Miemban. Clinical Case Report Competition. Utopia Academy. First Place Winner. Massage Therapists Association of British Columbia

Transcription

1 Massage Therapists Association of British Columbia Clinical Case Report Competition Utopia Academy November 2013 First Place Winner Christine Miemban The effects of neuromuscular technique on surgically repaired Achilles tendom rupture P: F: massagetherapy.bc.ca MTABC 2013

2 Table of Contents Acknowledgements 2 Abstract.. 3 Introduction 4 Case Subject History.. 6 Methods..8 Results 10 Discussion.. 14 Conclusion..16 References Appendix A 20 Appendix B

3 Acknowledgements To my case advisor, Aaron Ashe, thank you for all your help with this case study. Your insight has been extremely invaluable to me. To Jim Bowie, thank you for continuously sharing your knowledge with me. It has been a pleasure working with you and learning from you. 2

4 Abstract Objective: To determine if neuromuscular technique (NMT) performed on the gastrocnemius and soleus complex will increase ankle dorsiflexion and decrease scar tissue adhesion in an individual with surgical reattachment of the Achilles tendon, following an Achilles tendon rupture. Background: The subject is a 37 year old, healthy and physically active male. He sustained a complete Achilles tendon rupture to his left ankle while participating in an ultimate Frisbee game in June of Surgical reattachment of the Achilles tendon was performed one day following the injury. Methods: A series of 10 treatments were performed on the subject over a 5 week period. Treatments consisted of Swedish massage, followed by treatment of the left leg utilizing NMT on the gastrocnemius/soleus complex and scar tissue on the Achilles tendon. Results: Significant increases in both passive and weight bearing dorsiflexion have been observed. An overall increase of 17 degrees in passive dorsiflexion was recorded from treatment #1 to treatment #10 with a mean increase of 2.5 degrees at the end of each treatment. Knee-to- Wall Test measurements revealed an overall increase of 4.5 cm in weight-bearing dorsiflexion, with a mean increase of 0.49 cm with each treatment. Scar tissue adhesions decreased and pliability increased over the treatment period and width measurements were found to decrease incrementally over time. Conclusion: NMT, in conjunction with remedial exercises, was determined to be an effective treatment modality in the treatment of a surgically repaired Achilles tendon following a complete Achilles tendon rupture. Key words: Neuromuscular Technique (NMT), Friction, Achilles Tendon Rupture, Achilles Tendinopathy 3

5 Introduction A tendon is a fibrous tissue that serves to attach muscle to bone 1. The Achilles tendon is located on the posterior leg and attaches to the posterior portion of the calcaneal bone 1. It serves as a common tendon for the gastrocnemius and soleus muscles, both of which function in plantar flexion of the ankle 1. This function is essential as it allows individuals to walk, run, jump and stand on one s toes. Achilles tendon rupture occurs when the tendon itself is torn off of its attachment on the calcaneal bone 2. This tearing may occur anywhere along the tendon, as well as the musculotendinous junction. The exact mechanism of this injury remains unclear as it tends to occur spontaneously, particularly during sporting events or vigorous types of activities 2. It is thought that because the Achilles tendon is subject to large amounts of load in the body, repetitive stress to this tendon causes it to be susceptible to injury 3. Individuals who have sustained this injury often describe the initial sensation as if he/she was hit or kicked in the back of the leg, and there is often an audible sound 2. The gastrocnemius and soleus muscles are greatly affected and the individual is unable to plantar flex at the ankle. In addition, dorsiflexion becomes limited, especially with reattachment of the tendon 2. An individual is unable to lengthen the gastrocnemius and soleus and this can ultimately affect one s gait and ability to do certain activities. The injury occurs in 18 out of 100,000 people 4 and often occurs in athletes between the ages of 30 and 40 years, with a 10:1 ratio of males to females 2. A recent study, conducted in Edmonton, Alberta, Canada, determined that an average of 8.3 persons per 100,000 sustained an Achilles tendon rupture 5. 4

6 Debate currently exists over the optimal treatment for Achilles tendon ruptures. Surgical repair has been the preferred method, as several studies have indicated the rate of re-rupture after surgery is low 6,7. Although surgery is often the chosen method of treatment, some practitioners argue that it is unnecessary as the risk of infection and other complications are increased. Alternative treatments that have also been used in Achilles tendon rupture include cast immobilization and functional bracing 8. Functional braces or orthoses allow the ankle to be locked into plantar flexion. Adjustments on the brace can be made by a physician or physiotherapist to gradually move the ankle into dorsiflexion 8. Several studies support this nonconservative method. One such study indicated that 80% of subjects reported good to excellent results with the use of a customized polypropylene orthosis 9. Surgical intervention is often the treatment of choice and this typically involves reattachment of the Achilles tendon. Following surgery, the patient is casted in a plaster and/or fibreglass cast in a neutral position. If the patient is not casted, he/she is placed in a removable boot with wedges under the heel to allow the ankle to rest in plantar flexion. The wedges are progressively taken down to allow the ankle to gradually move into dorsiflexion 8. Physicians often recommend physical therapy following removal of the cast or when the ankle is able to move into a neutral position 8. The purpose of this case study is to determine if massage therapy can increase range of motion at the ankle joint, as well as decrease scar tissue size and adhesions, following surgical reattachment of the Achilles tendon resulting from a complete Achilles tendon rupture. It is hypothesized that: 1) Neuromuscular technique (NMT) performed on the gastrocnemius and soleus complex increases dorsiflexion of the ankle and 2) NMT on scar tissue decreases adhesions and tissue size. 5

7 Case Subject History The subject is a 37 year old male, who is a mechanical engineer. He currently maintains a physically active lifestyle, which includes weight training (3-4 days/week), kite boarding (1-2 days/week), ultimate Frisbee (1 day/week) and beach volleyball (1 day/week). No other conditions have been reported. In June of 2012, the subject participated in a 2 day ultimate Frisbee tournament. On day 1 of the tournament, the subject reported feeling good after having played two games. During the second game on day 2 of the tournament, the subject reported sprinting down the field and feeling a kick in the back of his left heel, causing him to fall to the ground. He did not experience any pain initially. He was taken to the hospital where radiographs confirmed the complete rupture. The Achilles tendon was surgically reattached to the calcaneus the following day. The subject was casted in dorsiflexion for one week in a plaster cast and 4 weeks thereafter in a fibreglass cast. Rehabilitation began after the cast was removed and entailed 3 days a week of physiotherapy, massage therapy and athletic training. Strengthening, increasing muscle mass and proprioceptive training were the main goals in physiotherapy and athletic training, while treating compensatory structures and decreasing scar tissue formation were the main goals in massage therapy. The subject continued with 3 days per week of treatments until the end of December of that year. Despite efforts to decrease scar tissue formation, a significant amount of scar tissue remains on the Achilles tendon. This, coupled with constant hypertonicity in the gastrocnemius and soleus muscles, has contributed to a decrease in range of motion at the ankle joint. Consequently, the subject has found a decrease in performance in the activities he partakes in. 6

8 The subject has not sought any therapy for his injury since the end of December of He currently presents with hypertoned gastrocnemius and soleus muscles, as well as limited dorsiflexion of his left ankle. A significant amount of scar tissue has formed around the surgical incision, as well as on the Achilles tendon and has resulted in restrictions in movement of the ankle. The subject continues to feel tightness in his left leg and in the area of the scar tissue and stretches both the gastrocnemius and soleus muscles when the tightness arises. 7

9 Methods Assessment Tools & Protocols Assessment took approximately 15 minutes before each treatment, and measurements were taken before and after each treatment. Range of motion of the ankle was taken using a goniometer with focus placed on active dorsiflexion and plantar flexion. In addition, dorsiflexion of the ankle with weight bearing was taken using the Knee-to-Wall Test 10 (Appendix A). Scar tissue widths were taken at 3 points along the scar using a skin-fold caliper at the end of each treatment session. The first point was measured at 14.2 cm from the floor; the second point was measured 12.2 cm from the floor; and the third point was measured 10.2 cm from the floor. These points were determined by the top, middle and bottom of the scar tissue in relation to the floor. Measurements for each point were taken three times and the average of these three measurements was then recorded. Assessment also included a Manual Muscle Test (MMT) of both the gastrocnemius and soleus muscles to gauge the muscles strength and functionality 11. The MMT was performed at treatments 1, 4, 7 and 10. Scar tissue adhesion and pliability was assessed with movement in 4 directions: superior, inferior, medial and lateral 12. Treatment Protocol The subject was treated for 60 minutes. Each treatment consisted of 20 minutes of Swedish massage and petrissage techniques on the right leg, as well as on the gluteal group, quadriceps, hamstrings and tibialis anterior muscles of the left leg. This was followed by 40 minutes of treatment to the posterior aspect of the lower left leg. NMT was performed on the gastrocnemius and soleus muscles to decrease hypertonicity 12. Longitudinal frictions and bowing were performed on the Achilles tendon to further lengthen the muscles. The scar tissue 8

10 was treated with bowing, picking up and peeling of the tissue off of the underlying structures. Cross-fibre frictions were incorporated in treatment of the scar tissue. Three 1.5 minute sets of frictions were performed on the tissue, with each set followed by passive stretching of the gastrocnemius and soleus muscles. The first set of frictions involved moderate pressure while the following two sets involved progressively deeper application of pressure. The three sets were then repeated along the scar tissue. The subject was advised to place ice on the left Achilles tendon over the scar after each treatment for 10 minutes. Passive stretches for the gastrocnemius and soleus were demonstrated and prescribed 2 times a day (once in the morning and once in the evening) and the subject was asked to hold each stretch for 30 seconds. Eccentric heel drops, both with the knee kept straight and with the knee bent, were prescribed to strengthen the gastrocnemius and soleus muscles 13 (Appendix A). This exercise was prescribed at 2 sets of 10 repetitions each and done once a day. 9

11 Results Increases in range of motion, particularly with dorsiflexion, were observed. The results for range of motion are located in Tables 1, 2 and Figures 1, 2. The results show linear increases in dorsiflexion over the course of 10 treatments. According to Figure 1 of the results, there are marked increases in passive dorsiflexion of the subject s left ankle following each treatment session. The mean increase in dorsiflexion before and after treatment was calculated to be 2.5 degrees with an overall increase of 17 degrees in the left ankle. Similar results are observed with dorsiflexion in weight bearing in the Knee-to-Wall Test, pre- and post-treatment (Figure 2). The average increase in dorsiflexion between pre- and post-treatment was calculated at 0.49 cm. Despite the small increases between the treatment sessions, the subject made an overall increase of 4.5 cm. The end measurement for the Knee-to- Wall Test was 11.7 cm. RANGE OF MOTION PRE- TREATMENT RANGE OF MOTION POST- TREATMENT Treatment # Dorsiflexion Plantar Flexion Treatment Dorsiflexion Plantar Flexion 1 R 16 o R 48 o 1 R 20 o R 48 o L 3 o L 48 o L 6 o L 49 o 2 R 20 o R 48 o 2 R 20 o R 48 o L 5 o L 48 o L 10 o L 50 o 3 R 20 o R 48 o 3 R 20 o R 48 o L 3 o L 48 o L 10 o L 50 o 4 R 20 o R 50 o 4 R 20 o R 50 o L 10 o L 50 o L 13 o L 50 o 5 R 20 o R 48 o 5 R 20 o R 50 o L 12 o L 50 o L 15 o L 50 o 6 R 18 o R 48 o 6 R 20 o R 49 o L 14 o L 47 o L 16 o L 50 o 7 R 18 o R 49 o 7 R 18 o R 49 o L 14 o L 48 o L 16 o L 50 o 8 R 18 o R 48 o 8 R 18 o R 50 o L 15 o L 50 o L 18 o L 50 o 9 R 18 o R 50 o 9 R 20 o R 50 o L 18 o L 50 o L 18 o L 50 o 10 R 20 o R 49 o 10 R 20 o R 50 o L 19 o L 50 o L 20 o L 50 o Table 1: Range of motion measured pre- and post- treatment 10

12 Dorsiflexion Measurements of LeP Ankle Range of MoCon (o) Treatment # Pre- Treatment Post- Treatment Figure 1: Progress in dorsiflexion of left ankle pre- and post- treatment KNEE TO WALL TEST Treatment # Pre- Treatment (cm) Post- Treatment (cm) 1 R L R L R L R L R L R L R L R L R L R L Table 2: Measurements of Knee to Wall Test pre- and post- treatment 11

13 Knee- to- Wall Measurement of LeP Ankle Measurement (cm) Treatment # Pre- Treatment Post- Treatment Figure 2: Trend of Knee to Wall Test measurements pre- and post- treatment Decreases in scar tissue size are seen in the following Table 3 and Figure 3. Images of the left Achilles tendon are seen in Appendix B. Each of the three measured points in relation to the scar tissue reported a total decrease of 8 mm, 4 mm and 5 mm, respectively. Furthermore, tissue pliability increased while adhesion decreased. Movement of the scar tissue in 4 directions (lateral, medial, superior and inferior) increased and the therapist was able to lift the scar tissue off the Achilles tendon. SCAR TISSUE WIDTH MEASUREMENTS Treatment # Post- Treatment (mm) Table 3: Measurement of scar tissue width pre- and post- treatment 12

14 Scar Tissue Measurements Post- Treatment Measurement (mm) Treatment # PosiCon 1 PosiCon 2 PosiCon 3 Figure 3: Scar Tissue Measurements post- treatment No changes were seen in the MMT of the gastrocnemius and soleus muscles. A grade of 5 for both muscles was recorded at treatments 1, 4, 7 and

15 Discussion Massage therapy, including Swedish and NMT, were effective in increasing range of motion and decreasing scar tissue adhesions after an Achilles tendon rupture and surgical repair. Limited literature exists in regards to Achilles tendon rupture and NMT. The results from this study are consistent with literature on the effects of neuromuscular technique on increasing range of motion and decreasing scar tissue adhesions 14,15. One such study s results indicated that the use of frictions increased the pliability of scar tissue due to the mechanical forces that induce change at the cellular level 15. In addition, massage therapy combined with remedial exercises, are consistent with literature on the use of eccentric exercises following repair of an Achilles tendon rupture 13,16,17. The subject reported a noticeable decrease in overall tightness of the gastrocnemius and soleus muscles and found an improvement in function while participating in physical activities. Furthermore, the restrictions around the scar tissue that the subject had experienced previously have diminished. The subject also found the remedial exercises to be of benefit, particularly on days between treatments. Physical therapy has often been chosen by physicians for rehabilitation of Achilles tendon rupture and repair. This study has given valuable information regarding massage therapy in the treatment of an Achilles tendon rupture. The results suggest that NMT effectively increased range of motion and decreased scar tissue adhesions. This information is beneficial for massage therapists as many therapists utilize NMT in the treatment of many pathologies. Since there is limited literature regarding massage therapy and Achilles tendon rupture and repair, the results of this study are encouraging for massage therapists and massage therapy provides an excellent adjunct to current therapies for this particular injury. 14

16 Despite the overall effectiveness of the case study, there are a number of limitations that need to be addressed. As this study focused on the results of one individual, it is important to note that the results seen in this study may not be representative of a larger population and therefore, a future study should include a larger sample size. The efficacy of the massage treatments versus the efficacy of the remedial exercises are yet to be determined, as it is difficult to say whether one or the other, or a combination of both, contributed to the success of the study. As such, it may be of benefit to consider utilizing massage therapy or remedial exercises rather than a combination of the two when conducting a study. This may aid in determining what the results are attributable to. Furthermore, this study only takes into account treatment of the Achilles tendon rupture and repair in a chronic state. Perhaps the results would differ if treatment was provided closer to the date of injury and repair, rather than a year following the injury. 15

17 Conclusion The effectiveness of neuromuscular technique on increasing range of motion in the ankle, as well as decreasing scar tissue size and adhesions, is strongly evident in this study. The results show a significant increase in dorsiflexion and slight decreases in scar tissue. 16

18 References 1. Tortora, G., Derrickson, B. Principles of Anatomy & Physiology. 13 th ed. Hoboken, New Jersey: John Wiley & Sons, Inc.; Brukner, P. and Khan, K. Clinical Sports Medicine. 3 rd ed. Australia: McGraw-Hill; Nandra, R., Matharu, G. and Porter, K. Acute Achilles tendon rupture. Trauma. 2011; 14(1): Aktas, S., Kocaoglu, B., Nalbantoglu, U., et al. End-to-End Versus Augmented Repair in the Treatment of Acute Achilles Tendon Ruptures. The Journal of Foot & Ankle Surgery. 2007, September; 46(5): Suchak, A., Bostick, G., Reid, D., Blitz, S., Jomha, N. The Incidence of Achilles Tendon Ruptures in Edmonton, Canada. Foot & Ankle International. 2005, November 1; 26: Nyyssonen, T., Saarikoski, H., Kaukonen, J., et al. Simple end-to-end suture versus augmented repair in acute Achilles tendon ruptures: a retrospective comparison in 98 patients. Acta Orthop Scand. 2003, April; 74(2): Bhandari, M., Guyatt, G., Siddiqui, F., et al. Treatment of acute Achilles tendon ruptures: a systematic review and meta-analysis. Clin Orthop. 2002, July; 431: Khan, R., Fick, D., Keogh, A., Crawford, J., Brammar, T., Parker, M. Treatment of Acute Achilles Tendon Ruptures: A Meta-Analysis of Randomized, Controlled Trials. Journal of Bone and Joint Surgery. 2005, October; 87(10): McComis, G., Nawoczenski, D., De Haven, K. Functional bracing for rupture of the Achilles tendon: Clinical results and analysis of ground-reaction forces and temporal data. Journal of Bone and Joint Surgery. 1997, December 1; 79(12):

19 10. Konor, M., Morton, S., Eckerson, J., Grindstaff, T. Reliability of Three Measurements of Ankle Dorsiflexion Range of Motion. The International Journal of Sports Physical Therapy. 2012, June; 7(3): Kendall, F., McCreary, E., Provance, P., Rodgers, M., Romani, W. Muscles: Testing and Function with Posture and Pain. 5 th ed. Baltimore: Lippincott Williams & Wilkins, Rattray, F., Ludwig, L. Clinical Massage Therapy: Understanding, Assessing and Treating over 70 Conditions. Elora, Ontario: Talus Inc.; Grigg, N., Smeathers, J., Wearing, S., Urry, S. Tendon rehabilitation: Isolated eccentric loading invokes a greater reduction in Achilles tendon thickness than concentric loading. Journal of Medicine and Science in Sport. 2008, January; 12: S Sorosky, B., Press, J., Plastaras, C., Rittenberg, J. The practical management of Achilles Tendonopathy. Clinical Journal of Sport Medicine. 2004; 14: Thuzar, S., Bordeaux, J. The Role of Massage in Scar Management: A Literature Review. Dermatologic Surgery. 2012, March; 48: Henriksen, M., Aaboe, J., Bliddal, H., Langberg, H. Journal of Biomechanics. 2009, December 11; 42(16): Fahlstrom, M., Jonsson, P., Lorentzon, R., Alfredson, H. Chronic Achilles Tendon pain treated with eccentric calf-muscle training. Knee Surgery Sports Traumatology, Arthroscopy. 2003, September; 11(5): Vicenzino, B., Branjerdporn, M., Teys, P., Jordan, K. Initial Changes in Posterior Talar Glide and Dorsiflexion of the Ankle After Mobilization With Movement in Individuals With Recurrent Ankle Sprain. Journal of Orthopaedic & Sports Physical Therapy. 2006, July; 36(7):

20 19. Griffiths, I. Ian Griffiths Sports Podiatry. 2010, February 28. Retrieved 2013, November Hoch, M., Staton, G., McKeon, P. Dorsiflexion range of motion significantly influences dynamic balance. Journal of Science and Medicine in Sport. 2010, January 21; 14(2011): Davis, J. Running Writings. 2011, August 22. Retrieved 2013, November

21 Appendix A Knee-to-Wall Test This test is also known as the Weight Bearing Lunge Test (WBLT). A tape measure is placed on the floor with the wall measured at 0 cm. The subject is then asked to place the tested foot next to or on top of the tape measure. A lunge is then performed with the second toe, centre of heel and knee perpendicular to the wall and the heel firmly on the ground 18. The subject lunges forward so that the knee touches the wall and the heel is still in contact with the ground. If the knee cannot touch the wall, the subject moves the foot closer to the wall and perform the lunge until contact with the wall occurs. Measurement is taken from the wall to the first toe. Figure A: Final position of test 19 Figure B: Patient positioning during the test 20 Eccentric Heel Drop Exercises A - The patient stands on the edge of a platform and stands on tips of toes. B - The patient then lowers one heel with the knee straight. Figure C: Positioning for heel drop exercises 21 C - Steps A & B are repeated with the knee bent after completing 10 repetitions with the knee straight. 20

22 Appendix B Treatment #1 Treatment #4 Treatment #7 Treatment #10 21