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Re: ACHILLES INFLAMMATION AND PAIN
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Re: ACHILLES INFLAMMATION AND PAIN - April 6, 2006 3:00:00 PM
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ginger
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From: Melbourne Victoria
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Steve J just reread last post, please amend thumb position . Don't point the thumb at a 45 degree angle into the patient, I meant that it is oriented on a horizontal plane at 45 degrees or so.thumbs need to be flat such that the most fleshey part is pushing down . I find the best comfort in a hyperextended d.i.p..
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: ACHILLES INFLAMMATION AND PAIN - April 6, 2006 6:44:00 PM
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physiosteve
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Thanks for that Ginger. I'll give that a go.
Steve.
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Re: ACHILLES INFLAMMATION AND PAIN - April 7, 2006 1:37:00 AM
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rwillcott
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If someone is complaining of Achilles pain then the first step is to determine the cause of the pain. If the patient reports a mechanism of injury, such as dropping back to complete a slant pattern and had immediate pain, then I would certainly treat the Achilles. However, if there is no mechanism of injury then I would agree with ginger that the root of this problem is more than likely the lumbar spine.
I think that this is where a detailed subjective history should not be overlooked. If we ask the right questions and listen to the patient they will explain to us the cause of the problem.
Thanks for the useful info. in this thread!
Rob
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Re: ACHILLES INFLAMMATION AND PAIN - April 7, 2006 1:47:00 AM
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rwillcott
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Ginger:
I have a few more questions about the lumbar spine mobs:
1. Do you place the patient in either a hyperextension (sphinx) or hyperflexed position when performing the mob?
2. Do you bother with positional testing to determine ERSR etc.?
3. Is it a straight PA of the spinous process or transverse process?
4. Are you concerned with the direction of the mobilization? Do you perform either a superior/anterior/lateral mob or a posterior/inferior/medial mob?
5. Is the thumb more effective than using the pisiform? Do you grade (1-4) the mob?
Any advice would be appreciated!
Rob
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Re: ACHILLES INFLAMMATION AND PAIN - April 7, 2006 5:41:00 AM
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aquatherapysc
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Although standard treatment for tendonitis, peritendonitis, tendinosis, and retrocalcaneobursitis is ice, rest, and nonsteroidal anti-inflammatory drugs; I most often incorporate a comprhensive program of stretching. As the patient progresses in his/her recovery I intensify the stretching program.
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Re: ACHILLES INFLAMMATION AND PAIN - April 7, 2006 9:30:00 AM
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treybien
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Don't forget to treat the soft tissue of the lower leg, especially gastroc and soleus. I use ART but whatever is fine. No miracles but can help up by decreasing internal tension and thus decreasing stress at the tendon.
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Re: ACHILLES INFLAMMATION AND PAIN - April 7, 2006 3:29:00 PM
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pwrandall
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From: Elk Grove, CA
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I can't believe I'm siding with Ginger (no offense please, I am always fascinated with your ideas and practiced a bit of ye old Maitland myself), but two things Lesain has mentioned have really jumped out: Night pain and in his last post he mentions that the pt. has concomittent LBP. Anytime a pt. mentioned LBP during the eval and came to me with a referral to me for distal LE symptoms I felt pretty confident distal intervention would be a waste of my time and as a conservative estimate I was 90% correct. Document findings and give the referring source a call or at least a note describing your suspicions (if neccessary in your jurisdiction and payor source) and treat as you see fit. Lesain, how is it going with this patient?
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Re: ACHILLES INFLAMMATION AND PAIN - April 8, 2006 2:06:00 PM
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ginger
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Hi Rob, I'll tackle your Q's in yourt numbered order.
Positioned in prone with one pillow under pelvis and chest , to maintain a stable slightly flexed lumbar posture.
As I'm not one to use abbreviations at all , you may need to flesh out ERSR and I'll get back to you.
Mostly unilateral mobs ( over the transverse process) though not limited to that. I may spend five minutes at the spinous process also , though this is less likely to produce the results I'm accustomed to.
The direction is rather predicted by what comes naturaly when access is limited to L5S1 in any case. I'm standing at a level just superior to the pelvis, with one thumb over the other. the direction changes according to what produces the two variables I'm interested in, pain and resistance. Pisiform mobs will not be sufficiently discrete in its penetration to L5S1.
Thumbs are best. Don't be put off by a little discomfort. Most of my students last about five minutes in the first week , progressing to 20 by week four at the end of a fourth year clinical placement.
The "grade" is determined entirely by resistance and pain. If no pain , go harder till there is some. It is the best indicator of improvement at the joint.
Go for it.
Don't treat the leg/ankle at all , at least not till the relationship between L5S1 is proven and results seen ( first and possibly second treatment ). Other wise you will just muddy the diagnostic waters. There is nothing to gain by treating the achilles in the majority of cases, where a clear realtionship is demonstrated as above. The results will be 100%, where no impact or tearing trauma has been a feature of the problem there. Don't forget to stretch Sciatic dura, a run down of this method has been descriobed in the manual therapy section.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: ACHILLES INFLAMMATION AND PAIN - April 8, 2006 5:45:00 PM
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BSLPTRMT
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on this issue of mobs - why not do Pa's as described for a short period of time and then if any rotation/relative limitation of mobility or pain persists perform a rotation away from the pain at L5/S1 in the Maitland fashion and at the grade that seems appropriate - usually GIV - initially for me - and with caution and reassessing after just 30 sec - ------I dont know about this lengthy mobilization you talk about - if it is the cause of the problem and you are at the right level and performing correct grade - possibly less rather than more then I couldnt imagine more than 3 times 30 sec. or at follow - up visits POSSIBLY 3 times 2 min.
I guess i go for less is more.
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Re: ACHILLES INFLAMMATION AND PAIN - April 9, 2006 11:49:00 AM
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rwillcott
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Ginger,
ERSR=Extended Rotatated and Side Bent Right
Based on positional testing of the lumbar spine in either the hyperflexed or hyperextended postion. Determined through palpation of the transverse processes in these positions. Of course this can be either right or left (ERSR or ERSL). It can also be Flexed Rotated Side Bent Right (FRSR) or left (FRSL).
I don't tend to rely on these to often, just wondering if you use them.
Also, why not manipulate L5/S1 instead?
Finally, do you have a hard time explaining the rationale of this technique to patients? Sometimes they have a hard time believing that their pain is caused by their back.
Thanks for the explanation thus far!
Rob
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Re: ACHILLES INFLAMMATION AND PAIN - April 9, 2006 12:43:00 PM
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JLS_PT_OCS
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I think I'm starting to agree with ginger. If I went to someone for a peripheral problem and they proceeded to push on my spine continuously for 20-30 minutes each treatment, I think I would decide I was cured by the second or third visit, too! One could only take so much of that "treatment".
"Oh, no, it's all better now, please don't push on my bones anymore!"
:)
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: ACHILLES INFLAMMATION AND PAIN - April 9, 2006 5:35:00 PM
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ginger
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Jason , now don't go agreeing with me , I'd much rather keep you as a protagonist, your delicate way with words keeps me alert.
Rob , I have no problem explaining my treatments, for the most part , those who find their way to me do so at the encouragement of friends , family or others who refer to me. They come with an expectation that I'll deal differently from those who, for instance, saw their problem as peripheral.
The way to establish rapport of course is to explain , followed by early signs of pain relief with mobs. There is usually a reduction in palpable tenderness to achilles structures within 5 minutes of commencing L5S1 mobs .
I did mention the limitations of manipulations in an earlier post, which is ,don't bother, pulling joints apart won't induce a loss of protective responses as powerfully as mobs, neither will it give a lasting effect.
I don't as a rule use back positional testing, I prefer to acknowledge joint pain and stiffness directly with mobs.
BSLPTRMT,
I'm a little pushed for time today to go into the continuous method in detail , if you go to the archives in the open forum section you will find a body of work there beginning with " the physiology of spinal pain, a theoretical model ", which should give you an insight into my preference for the continuous method.
cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: ACHILLES INFLAMMATION AND PAIN - April 9, 2006 6:14:00 PM
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rodgere
Posts: 49
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From: Linden
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yes the spine is overlooked to often. But has anyone ever used or seen ASTYM. I got certified in this and it is outrageous. check it out. ASTYM has fixed all my heel pain patients including plantar pain
http://www.performancedynamics.com/patients.htm
Take this cource you will be happy
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Re: ACHILLES INFLAMMATION AND PAIN - April 10, 2006 12:37:00 AM
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nari
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From: Australia
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R,
I read through what I think they do as a treatment, and it seems to be just neuromodulatory effects through the skin receptors. Can you elaborate on how you treated your heel pain patients?
Nari
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Re: ACHILLES INFLAMMATION AND PAIN - April 10, 2006 6:33:00 PM
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rodgere
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From: Linden
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its funny bc someone started a new discussion. its called astm but it is really ASTYM. its just an agressive deep tissue massage. you use these tools to scrape the skin. it kickstarts the healing process by bringing blood to the area. not a bad treatment. i see about 20 a day and i used it on 3-4 patients per day. awseome for Plantar fasciitis type complaints.
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Re: ACHILLES INFLAMMATION AND PAIN - April 11, 2006 7:54:00 AM
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truthseeker
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is it the same type of rationale as the sound blaster thingy that some are recommending for plantarfasciitis?
They go in and the doc puts them under general anaesthesia then puts some type of high powered sound head against their heel and Bammo!!! it magically fixes their pain.
Only the one patient I had who did it experienced no improvement.
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Re: ACHILLES INFLAMMATION AND PAIN - April 11, 2006 8:37:00 AM
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physiosteve
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Ginger,
To follow up on my earlier post. I did try the mobs on my patient. In the direction you suggested, with my two thumbs "stacked" to prevent (hopefully) onset of OA at 1st CMC in yours truly. 10 minutes continuous mobs (maybe should have gone longer?) at GIV, producing pain at the beginning and then no pain after about 5 minutes. At that point, I changed orientation/placement slightly with the result that the patient reported discomfort for another two to three munutes, followed by pain-freee mobs for the last two minutes or so. I did not position her in slight flexion (although this may have made sense, if I am envisaging any sort of "opening" of the L5-S1). This is a patient with a largely swollen area at the right achilles - sort of like she has a half golf ball sewn in there. She reports that the swelling has reduced since initial onset in December(!). History is that she had a tear of the achilles about fifteen years ago while playing soccer, and was managed conservatively with splinting followed by physiotherapy. Given that there is a distant episode of trauma, my first line of treatment on initial visit was to directly address the achilles, including beginning the eccentric protocol as outlined earlier in this post. The tenderness and swelling are mid-tendon, and Alfredson et. al. do note that the eccentric has greater success with this type of pain than with insertional pain cases.
I am not sure if the chronicity and recent recurrence of this problem would increase the liklihood of lumbar spine involvement. Thoughts, anyone?
Anyway the results of the mobs: there was reduction in swelling at the achilles, in that swelling was more diffuse and less of it poking out the back of the achilles. Not sure about tenderness changes, really.
Interestingly, this patient has massive gastrocs - should be referred to more as cows than calves. I wondered when assessing her if there was an imbalance between the strength of the ankle extensors and the strength of the tendon, and if this had predisposed her to the tear at age nineteen.
Thanks for your help in describing your techniques. I will repeat the mobs first thing next visit and look again for changes directly after.
Steve.
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Re: ACHILLES INFLAMMATION AND PAIN - April 11, 2006 11:43:00 AM
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rodgere
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From: Linden
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hey tom not sure about the soundblaster. I have heard of it. all I can say is I have had good luck with it; astym. but a always feel that non traumatic pain is coming from the spine. I know I'm going to get stoned for that comment.
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Re: ACHILLES INFLAMMATION AND PAIN - April 11, 2006 12:52:00 PM
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drbuddy
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ASTM, AYSTM, GASTM, SASTM... They are all describing the same thing. The only difference is the organization that teaches it. There is Performance Dynamics, Graston, Carpal Therapy Inc, etc.
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Re: ACHILLES INFLAMMATION AND PAIN - April 11, 2006 2:05:00 PM
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ginger
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From: Melbourne Victoria
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Steve, well done with a decent burst at the method, interesting to hear a more detailed history . I can't imagine how big cows could have disposed her to failure at her achilles though. Some people have amore pronounced push off in their gait , where they are seen to bounce along. This might account for her hypertrphy. Long periods of even a mild limp could account for a lumbar protective response leading to sciatic irritation.
I mostly see a reduction in swelling about 24 hours after mobs, though palpable tenderness will be reduced immediately. Squeeze a bit , mob a bit.
Mr(?) Evans, you won't get stoned from this side of the Pacific, just encouraged.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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