WEEK 11 - TENDINOPATHY AND MANUAL THERAPY FOUNDATIONS

Question 1

Tendinopathies: Red Flag Screen

Answer 1

Tendinopathy can be part of a bigger problem:

Mindful of sudden onset, high pain, traumatic tendon injury - potential for tendon rupture

Systemic red flags – infection, inflammation, malignancy

Neurological red flags – numbness/tingling, weakness, loss of power, changes in ability to use hand/foot?

Spondyloarthroparthy - abnormal enthesis - usually achilles.
Other aspects - psorasis, colitis or chrohns, early morning stiffness, genetic predispostion

Question 2

Select and execute diagnostic tests appropriate for common tendinopathy presentations (achilles).

Answer 2

Thompson’s test

Have the patient lie prone on an examination table with their feet hanging off the end.

Ensure the ankles are relaxed and the feet are visible.

The examiner squeezes the calf (gastrocnemius and soleus) of the affected leg.

Observe the foot for any movement (plantarflexion).

Normal Response
- Foot plantarflexes when the calf is squeezed → Achilles tendon is intact.

Positive Test
- No plantarflexion of the foot → suggests a ruptured Achilles tendon.

Partial movement
- May indicate a partial tear of the tendon.

Other tests:
- tendon loading - functional assessment
- walking, calf raises, STS
- be aware of warm up phenomenon, adaptive movement behaviours, pain and muscle performance

tendon lengthening assesment
- knee to wall test - assess for compressive pattern of pain

palpation
- mid portion vs insertional tendinopathy - TOP

observation
- localised inflammation, fusiform, muscle retraction

AROM/PROM
- reduced results, pain at terminal dorsi due to compression

Question 3

Select and execute diagnostic tests appropriate for common tendinopathy presentations (hamstring).

Answer 3

Compressive pattern - pain in excessive hip flexion

Functional assessment - DL bending forward, if irritability is mild, SL bend forward

TUP over proximal insertion of hamstring

AROM/PROM
- reduced results, pain in terminal hip flexion

Question 4

Select and execute diagnostic tests appropriate for common tendinopathy presentations (gluteal).

Answer 4

Special test - Ober’s test
Bring top (affected) hip into hip ext and slight knee flex
Lower leg into hip add to test for compression at gluteal insertion point

Presentation - usually comes on as a result of poor pelvis instability and surrounding muscle weakness (glute min/med) MMT + AROM/PROM

Functional test - figure 4 sitting assessment - compression pattern

Question 5

Select and execute diagnostic tests appropriate for common tendinopathy presentations (patella).

Answer 5

Compressive pattern found in excessive knee flexion, reduction in AROM/PROM with pain in terminal knee flexion

Presentation - young athletes in explosive sports (volleyball, AFL, basketball) involved in excessive jumping resulting in load intolerance and/or patella tendon degeneration

Question 6

Understand the four key questions to consider when determining if Manual therapy is appropriate.

Answer 6

• Patients goals of Physiotherapy care include pain reduction and movement improvement
• Patient Activity limitations and Participation restrictions are due to impairment of movement
• Patient expects manual therapy
• Prior experiences of Manual therapy have led to positive outcomes

Question 7

Recognise that the when, where and how of applying manual therapy depends on a number of patient and therapist factors. Responder vs non responder considerations

Answer 7

• Responder vs non-responder - considerations:
  
  • Sensitivity/irritability
  • Pain severity
  • Underlying cause of the pain and movement restriction (neuromuscular vs specific cause)
    
    • Specific causes that limit movement
      
      • Rheumatoid Arthritis
      • Fracture/Osteochondral fragment
      • Swelling/Injury acuity
• Indication for manual therapy in that specific patient
• Safe and comfortable
  
  • `Safe = skilful
• Skilled handling
• Patient’s confidence in you
• Your own confidence
• Measure outcomes

Question 8

Explain some of the important clinical reasoning decisions in determining the appropriate application of manual therapy.

Answer 8

• Clinician centred assessment
  
  • Patho-anatomical reasoning
  • Biomechanically focused
  • Joint dysfunction/muscle spasm or tension requiring ‘manual correction’ in some way
• Technique specificity
  
  • For example;
    
    • Compressive pattern of pain and movement restriction at C4/5 on R side = Downslope at C4/5 on R side
    • 30 secs, grade 3, 1-3 sets, 60-120hz, re-assess