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Case Study: Subjective and Physical Assessment
A sports technician has presented with 2 dissimilar pains in their right ankle, 3-weeks ago after increasing training from inconsistent cross-fit and swimming sessions to their current routine; two CrossFit sessions, two 60-minute boxing sessions and three 20-minute jogs. Pain 1 is a localised, sharp pain with a VAS of 7/10, occurring immediately through running, jumping or stair walking. This subsides immediately into pain 2; a dull ache with a VAS of 4/10, easing after 90-mins with rest and ice. Stiffness within ankle felt during the morning but sore in the evening. Ibuprofen is taken to deal with the pain. The first 2-weeks; calf tightness was felt and managed through stretching and foam rolling. A week ago, Pain 2 was felt after a 50-min trail run. The client felt stiffness the following day and completed a cross-fit session with intermittent pain 1 and calf tightness throughout session.
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The medical history provides 3 previous injuries. Firstly, recurrent right ankle sprains, last occurring one year ago and completing no rehabilitation or treatment. Secondly, a right fibula stress fracture suffered 2 years ago, obtaining no medical advice, only to rest before returning to training. Thirdly, intermittent lower back pain experienced for 3 years.
Within the subjective assessment, the medical history and modified training workload lead to a primary hypothesis of Achilles tendinopathy. The main stimulus as high repetitive stress or load placing the tendon beyond its physiological tolerance, causing degeneration or micro-injuries with reduced performance due to pain or swelling (Van Sterkenburg & Van Dijk, 2011). This occurs during activities requiring the stretch shortening cycle such as running and jumping, activities included within the patients training (Kountaris & Cook, 2007; Cook & Purdam, 2009). Factors such as; training errors, previous injury, gastrocnemius–soleus dysfunction, muscle weakness or lower limb misalignment are associated with Achilles tendinopathy (Azevedo, Lambert, Vaughan, O’Connor & Schwellnus, 2009; Van Sterkenburg & Van Dijk, 2011). Common symptoms include morning tendon stiffness, pain during and after exercise and tenderness on palpation (Van Sterkenburg & Van Dijk, 2011).
A reactive tendinopathy occurs with acute tensile or compressive overload, triggering short-term thickening of the tendon; reducing stress or allowing adaption to compression and increasing tendon stiffness (Cook & Purdam, 2009). Acute overload can be associated to two pain mechanisms; firstly, pain localized to the tendon when provoked and secondly, sharp pain provoked by loading with ensuing muscle contraction, subsidising when loading concludes. Cook and Purdam (2009) present a tendinopathy continuum; continual overloading causes tendon disrepair and degeneration. Reactive tendinopathy results in increased tendon cross-sectional area through swelling caused by short-term proliferative (Kountaris & Cook, 2007; Cook & Purdam, 2009).
Recurrent ankle sprains may result in damage to the anatomical structures through repeated ankle inversion leading to joint mechanoreceptors weaknesses. Lee, Lee, Choi, Jung and Jang (2018) suggest causes of recurrent ankle instability through mechanical laxity, a pathologic laxity through loss of ligamentous complex function or functional ankle instability, a lack of neuromuscular control and proprioception. This results in postural and chronic ankle instability linked to lower limb muscle weakness or muscle imbalance(Pourkazemi, Hiller, Raymond, Nightingale & Refshauge, 2014; Lee et al., 2018). Fibula stress fractures, located in the lower fibula proximally to the tibiofibular ligament, result from excessive repetitive submaximal bone loading without sufficient rest (Hoglund, Silbernagel & Taweel, 2015). Causes can be muscular forces acting on a bone or exhaustion of supporting structures. Increased scar tissue restricting surrounding soft tissues and tightness can be a result of insufficient rehabilitation.
Lower back pain (LBP) is a result of altered lumbar lordosis and pelvic tilt due to morphological and postural factors (Chaléat-Valayer et al., 2011; Paungmali, Henry, Sitilertpisan, Pirunsan & Uthaikhup 2016). Changes are caused through tightness or weakness of various muscle groups such as iliopsoas muscles, gluteus medius or gastrocnemius, leg length discrepancy, excessive foot pronation and hip adductor-abductor imbalances (Hoy et al., 2014; Cooper et al., 2016). Hartvigsen et al., (2018) have suggested that LBP can be associated with neurological symptoms or pain in the legs.
Several differential diagnoses can be determined from the client’s subjective assessment. Firstly, posterior ankle impingement syndrome (PAIS) results from forced plantarflexion or overuse in repetitive plantarflexion (Brukner & Khan, 2017). This results in soft tissue impingements around the tibia, posteriorly, and calcaneus, superiorly with a sharp, dull, radiating pain and catching or locking (Hayashi et al., 2015; Lavery, McHale, Rossy & Theodore, 2016). Secondly, peroneal tendinopathy results from repetitive mechanical stress, presenting with pain and swelling, posterior to the lateral malleolus, during active, resisted eversion and dorsiflexion (Brukner & Khan, 2017). These are associated with recurrent ankle sprains and instability (Park et al., 2010; Ribbans, Ribbans, Cruickshank & Wood, 2015). Thirdly, insertional Achilles tendinopathy results from excessive load, overuse and poor training habits (Brukner & Khan, 2017). It presents with localised pain and morning stiffness and aggravated by exercise, stair climbing, running on hard surfaces (Sayana & Maffulli, 2005). Retrocalcaneal bursitis presents with inflammation of the bursae causing irritable pain and swelling around the Achilles tendon and posterosuperior border of the calcaneus and is a result of landing awkwardly or hard on heel and pressure from footwear (Agyekum & Ma, 2015).
An appropriate physical examination follows the subjective assessment. The aim is to diagnose or disprove possible hypotheses with factors (severity, irritability and pain mechanisms) influencing how the physical examination occurs (Petty & Ryder, 2018).
To confirm the primary hypothesis of Achilles tendinopathy; appropriate palpation, end of range movements and physical tests would be carried out to reproduce pain and symptoms. The subjective assessment provides positive findings for the hypothesis, the client points to the mid-portion of the tendon where pain occurs, the type of pain described and tendon stiffness worse in the mornings (Brukner & Khan, 2017).
The physical examination should start by exposing both legs from the knees downwards where the patient would be both standing and prone. Observation and palpation of the structures would occur assessing alignment, muscles and tendon shape, tenderness, areas of pain or crepitation, erythema, heat and swelling. Inspection up the kinetic chain should occur to inspect postural or structural deviances (Kader, Saxena, Movin & Maffulli 2002; Brukner & Khan, 2017). Positive findings, here, would include tenderness along the midportion of the tendon, subjective tendon thickening and subjective crepitation with passive ankle movements (Paavola, et al., 2002; Longo, Ronga & Maffulli, 2018).
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Range of motion should be assessed through various tests. Simpson and Howard (2009) suggest a decrease in ankle dorsiflexion and plantarflexion would be observed. A painful arc sign test differentiates between tendon and paratenon lesions, with positive findings showing tendinous lesions moving with plantarflexion and dorsiflexion (Brukner & Khan, 2017). Often, discrete swelling where tenderness is present significantly decreases or disappears when the tendon is put under tension (Longo et al., 2018). A Royal London Hospital test assesses tenderness during end range dorsiflexion through palpation along the portion of the tendon initially tender with a positive finding showing tenderness in end range dorsiflexion (Burkner & Khan, 2017; Longo et al., 2018).
Hutchinson et al., (2013) suggest functional tests that put a load through the tendon in end range of motion as part of the physical examination, simulating functional movements that aggravate symptoms. A knee-to-wall test would be completed, placing the client into passive ankle dorsiflexion and knee flexion, where a positive finding is pain during dorsiflexion. Furthermore, completing a single leg heel raise would put the ankle through resisted plantarflexion, with a positive finding showing pain on resisted plantarflexion or movement. Lastly, a hop test providing plyometric load can be completed, with positive findings showing pain in the mid Achilles tendon during loading (Brukner & Khan, 2017).
Hutchinson et al., (2013) have suggested that only a few of the assessment and diagnostic tests for Achilles tendinopathy were found to be adequately accurate and trustworthy for clinical use. Therefore, appropriate physical examination should be carried out to confirm the primary hypothesis and exclude differential diagnose.
Diagnosis of PAIS starts with observation occurring around the ankle and foot assessing alignment, effusion, or swelling. Palpation of the bone and soft tissue structures occur mainly along the posterolateral talocrual joint line and posteriorly to the medial and lateral malleolus (Lavery, et al., 2016). Localized tenderness over the posteromedial aspect of the joint is a positive finding, although difficult to provoke tenderness can be reinforced through big toe passive flexion and extension (Yasui Hannon, Hurley & Kennedy, 2016). PAIS will present with restricted dorsiflexion due to pain or mechanical blocks and pain on end range passive plantarflexion (Senecal & Richer, 2016). A posterior impingement test will present with pain over posterior aspect of ankle during passive plantarflexion (Brukner & Khan, 2017).
Diagnosing peroneal tendinopathy, palpation and observation would occur around the ankle, bones and soft tissue structures. Here, peroneal tendinopathies would present with tenderness, crepitus, swelling or thickening within the tendon including an increased varus foot position (Simpson & Howard, 2009; Brukner & Khan, 2017). Simpson and Howard (2009) suggest a peroneal tunnel compression test, this presents pain along the fibula, posteriorly, with active dorsiflexion and resisted eversion. During range of motion assessment, pain would occur during passive inversion and plantarflexion and resisted eversion (Selmani, Gjata & Gjika, 2006; Brukner & Khan 2017). A manual muscle test of the peroneal muscle group should be performed assessing eversion and plantarflexion strength; positive findings suggest weakness and can be a result of pain (Brukner & Khan 2017). Commonly, a subjective history of chronic lateral ankle pain and instability are present, like the clients’ subjective history (Simpson & Howard, 2009). Symptoms are triggered by sustained or recurring activity or acute traumatic incidents (Selmani et al., 2006). Therefore, appropriate functional tests that worsen symptoms such as weight bearing lunges, walking or jumping should be completed with pain occurring during exercises as a positive finding. A peroneal tunnel compression test produces pain within the peroneal brevis tendon, and a special test assessing strength during plantarflexion, shows weakness and dysfunction of the peroneus longus tendon (Selmani et al., 2006).
Insertional Achilles tendinopathy examination with observation and palpation would reveal tenderness and thickening or nodularity at insertion (Sayana & Maffulli, 2005) limited dorsiflexion would also be present. When assessing retrocalcaneal bursitis, palpation and observation would show tenderness, swelling, redness and pain medially and laterally around the Achilles tendon and above the posterosuperior aspect of the calcaneus (Aldridge, 2004). Kondreddi, Gopal and Yalamanchili (2012) describe sharp pain during dorsiflexion when assessing joint range of motion. Functional tests such as calf raises should be completed to elicit symptoms, here irritable pain would be present. Presents on low-load activities such as heel raises, end-range dorsiflexion or prolonged standing (Aldridge, 2004; Agyekum & Ma, 2015).
The subjective history of recurrent ankle sprains, fibula stress fracture and lower back pain suggest possible biomechanical issues that result in these injuries. Paavola et al. (2002) suggest those with symptoms of Achilles tendinopathy should be examined for ankle instability and biomechanical faults due to gastrocnemius–soleus dysfunction, muscle weakness and lower limb misalignment. associated with an Achilles tendinopathy.
A contributing factor of an Achilles tendinopathy is restricted dorsiflexion due to an increased tendon load. This can lead to overpronation to allow further movement, causing lower limb misalignment causing posture to change and muscles to become taught or lengthened (Hoy et al., 2014). Nourbakhsh and Arab (2002) describe how lower back pain is caused by changes in the size of the lumbar lordosis and pelvic tilt because of morphological and postural factors such as muscular weakness or tightness (Paungmali et al., 2016). Tightness or weakness among muscles such as iliopsoas, gluteus medius or calf muscles may cause over-pronation and hip adductor-abductor imbalances (Chaléat-Valayer et al., 2011; Cooper et al., 2016). Furthermore, Pourkazemi et al. (2014) have found that lower limb muscle weakness or muscle imbalanceare associated with recurrent ankle sprains, another factor associated with Achilles tendinopathy. This can be affected through increased ankle instability and laxity and a loss of neuromuscular control and proprioception (Pourkazemi et al., 2014).
Observational examination can be used to identify any pelvic tilt, altered posture and over pronation. Petty and Ryder (2018) suggest assessing joint stability and integrity after recurrent ankle sprains through a joint integrity test, an anterior drawer sign test and talar tilt test. Furthermore, decreased dorsiflexion can be found when assessing range of motion and a weight bearing lunge tests (Brukner & Khan, 2017). Assessment of muscle strength during plantar and dorsiflexion can be assessed through strength tests such as a single leg heel raise with positive findings showing relative weakness and dysfunctions in plantarflexion strength (Brukner & Khan, 2017; Petty & Ryder, 2018). Functional tests such as lunge or walking to assess gait analysis and over pronation of foot and posture (Agyekum & Ma, 2015).
Completing an appropriate physical examination eliciting the symptoms can confirm the primary hypothesis, reject alternative diagnosis and address the predisposing factors.
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