Achilles Tendon Sprain Case Study

Name: Lani Thompson

Age: 26

Sex: Female

Occupation: Merchandiser

Height: 179

Weight:77.8, BMI:

Diet: Mixed

Family: She lives with her partner, no kids.

Medical History: No history of Hypertension, Cardiovascular, Diabetics mellitus, pulmonary or any chronic disease.

Footwear: A comfortable, properly fitted footwear should be used. Avoid High heels.

Daily activities: Usually she goes to Gym thrice in a week, occasionally she goes for swimming.

Balance:

Muscle performance: No muscle wasting.

Posture:

Circumferential measurement:

Alignment: There is no difference in alignment while she walks.

History: Lani Thompson is a hockey and rugby player. About 4 months back, while she was training rugby she had a right ankle sprain. The Incident was happening around 7 in the night. Soon after she was shifted to the hospital and consulted with the doctor. On the same day she had undergone several investigations and examinations, including X-Ray and ultrasound. No evidence of any fracture on the x-ray and was diagnosed as an Achilles tendon sprain. Initial 2 weeks she was in a brace, subsequently she started ankle exercises. Later she exercised with Theraband and had started physiotherapy treatment for 2 weeks, eventually continued her exercises at home.

Past Medical History: She has never been hospitalized for any chronic diseases. No history of Diabetes mellitus, Hypertension, Heart diseases, Asthma, Hepatitis, Sexually transmitted diseases or Tuberculosis.

She regularly takes medications for depression/anxiety and for contraception.

Medication: Venlafaxine, Quitiepine and a contraceptive pill.

Surgical Intervention: No surgical interference.

Gait pattern: Altered, limping of right leg.

Range of Motion (ROM): Normal on left side, right ankle ROM is slightly altered, No muscle stiffness.

Palpation: No tenderness or any abnormalities.

Anatomy of the Ankle joint: The ankle joint mainly consists of two joints, the subtalar and the true ankle joint. The subtalar joint comprises three bones, the tibia, the fibula and the talus. The mechanism of the ankle joint is very complex. True ankle is responsible for the up and down movements of the foot. The subtalar joint is positioned under the true ankle joint and consists with two bones, the calcaneus and the talus. This joint is responsible for the side to side movement of the foot. The joint is covered with a cartilage known as articular cartilage. The articular joint is lubricated with synovial fluid.

Many ligaments connect the ankle bones together, they are anterior fibular ligament, which attaches the fibula to the tibial bone. The second ligament is known as the lateral collateral ligament, which connects calcaneus bone with the fibula and the tibial bone and the third one is deltoid ligament, it connects calcaneus and the talus bones together to the tibia.

Many tendons attach the muscles of the lower limb and the bones of the ankle, they are the Achilles, the flexor hallicus longus, the flexor digitorium, the peroneal tendons, the posterior tibialis and the anterior tibialis tendons. Among these tendons the Achilles tendon is considered to be the strongest tendons in the human body. It is located at the posterior of the leg and connects the calcaneus bone to the gastrocnemius ,solens and plantarius muscles. The Achilles tendon is about six inches long and can withstand around four time of body mass during walking and almost eight times while running.

Achilles Tendonitis: It is the inflammation of the calcaneus tendon.Over use of the tendon causes pain and stiffness, for instance running up hill or climbing up stairs.

Achilles Rupture: asdf……..

Exercises:

Group 1 Exercise:

Evertion/ Invertion isometric exercises.

Evertion: This exercise can be performed by placing the injured foot adjacent to a door or the leg of a table and gradually push extremely to the lateral side of the foot.

Inversion: This exercise can be done by placing the medial aspect of the foot to any fixed objects such as a table leg or a door, then to push gently outward –in for two to three seconds.

Evertion/Invertion with an exercise band:

Evertion: The client has to sit and fix the leg straight, with the help of an elastic band One end of the elastic band is attached to a table leg and other to the foot and then gradually turns the foot outwards.

Invertion: Rotate the foot inwards by reversing the position of the band .The movement of the foot should be apart from the leg of the table.

The client can proceed to the group two exercises, if he tolerates to do group one exercise.

Group 2 exercises:

Gastrocnemius stretch: The patient has to bend forward and push the wall with his hands. The injured leg should be placed just behind the other foot, keeping the foot firmly to the floor for about 30 seconds.

Soleus Stretch: Place the non injured foot behind the injured foot and bend the other knee joint. The heel should be raised while stretching.

Weight bearing exercises: The client should stand on the floor with the affected leg and bend the other leg, so that the whole body weight should bear on the injured leg for 30 seconds and then lift the heel up and down.

Injured leg stand with a cloth:

The client is asked to stand on a 2inches thick cloth with the injured leg for 30 seconds.

The client can proceed to the group three exercises, if he tolerates to do group two exercises.

Group 3 exercises:

Lateral step and bound exercise.

This exercise is performed by placing a folded towel on the floor and to stand beside the towel and client steps on the folded towel. Other foot should be placed firmly on the floor. Repeat the same exercise with other leg. As the pain allows, increase the repetitions and speed accordingly.

Hop exercise: It is performed by placing a folded towel on a floor and the client is asked to stand beside the towel and bound over the folded towel and to rest on the other foot. Then reverse the entire exercise with the other leg.As the pain allows, slowly raise the speed and hops.

Rehabilitation:

Range of movement:

Stretching of the calf muscle:

When the patient will be able to sand comfortably with an injured leg, he is asked to move back the injured foot and move the hip gradually forward, so that the calf muscle is stretched. Hold for 20 seconds and repeat for at least 2 times per day.

Alphabet writing: The patient has to write alphabets with his greater toe at least 2 times per day.

Balance training exercises: By holding a fixed object firmly with one hand and stand on a single leg, keeping the other knee folded. Repeat the same with the other foot as well. As the patient’s balance improves, he is encouraged to repeat the same exercise with eyes shut.

GOALS:

• Short term: Phase 1 and 2

• Improve joint range of motion and flexibility
• Increase ankle strength
• Gain normal gait pattern
• Progressive Proprioception and motor coordination

• Long term: Phase 3 and 4

• Improve cardiovascular endurance
• Return to complete sports activity

• Rehabilitation program involves:

• Stretching of the calf muscle and around the ankle muscle
• Strengthening exercise
• Deep massage techniques
• Cardiovascular endurance exercise
• Agility training

Phase 1: T o gain range of motion

Stretching-

Calf plantar fascia stretch:

Sit on the floor with leg extended and knees straight

Loop a towel around the affected leg and grip the end of towel on each hand.

Affected leg should be in straight and pull the towel near the body

Hold the position as same for 30 seconds and relax

Repetition: 3 to 5

Calf muscle stretching:

Open kinetic chain exercise:

Toe curls

Marble pickups

Four-plane surgical tubing exercises

Sub maximal Isokinetics in short arc

Strengthening exercise:

Plantar flexion exercises with Theraband

Inversion and eversion exercise isometric exercise

Flexibility:

Grade 1 and 2 mobilization

Alphabet ROM

Proprioceptive:

Stork standing

Single plane tilt board

Biomechanical ankle platform system in non-partial

Weight bearing position.

Cardiac endurance exercise:

Pool therapy

Stationary cycling.

PHASE 2:

Stretching:

Achilles stretches in sitting and standing positions

Open kinetic chain exercise: full –arc ISO kinetics

Close kinetic chain exercise:

Shuttle squats

Heel raises

Toe raises

Tubing lunge steps

Proprioception:

Wobble board work

Walking on uneven surface

Biomechanical ankle platform system with partial

Cardiac endurance training:

Treadmill Stairmaster

PHASE 3:

Program in this phase should be considered according to the

Strength and progression of the client.

The program involves dynamic and functional tolerance of the patient.

Start up with increase weight bearing force on the ankle joint

Stretching of Achilles tendon in a supinated position

Eccentric heel drop with knee straight

Eccentric heel drop with knee bent

Lunges and squats

Step ups

Side step ups with weight bearing

To focus on lateral stability –up and down sideways movement

Back pedalling exercise

Caricos

Plyomettric drills

Proprioception:

Ladder drill Netball throwing and catching with Standing on the affected leg moving to catch the ball and return to land on the same leg.

Four square hopping drills

Agility training:

Shuttle running with changing the direction

Zigzagging or figure of 8 runs

Phase 4: functional rehabilitation activities such as tip toe walking.

Polymeric progressions –hopping, bounding, depth jumps and box drills

Sport-specific training

Unstable surface training

Stationary cross country skier

Ensure normal plantar to dorsiflexion strength ratios and muscle balance

Careful increase in training regimens