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Physio Matters

Achilles Tendinitis

The Achilles tendon is a tendon at the back of the leg that attaches the calf muscles (gastrocnemius, soleus, and plantaris) to the heel bone (calcaneus), and is considered to be the thickest tendon in the body. It is responsible for plantar flexion of the foot (pointing or pushing off from the toes), and flexion of the knee, which are especially important for walking. Tendinitis refers to inflammation of a muscle, which is most often due to repetitive motions or overuse. Other causes may include a sudden increase in activity, tight calf muscles, or bone spurs (extra bone growth) present where the tendon attaches to the heel bone. Pain and swelling are common symptoms of inflammation, which typically occur at the heel or along the tendon. The tendon may also be visibly red and warm to the touch, and it may be difficult to point or push off from your toes when standing. In addition, people that suffer from Achilles tendinitis will typically experience thickening of the tendon, stiffness in the morning, have an increase in pain following activity or exercise, and limited range of motion of the foot.

There are two types of Achilles tendonitis: Non-insertional Achilles tendinitis and insertional Achilles tendinitis. The non-insertional type affects the muscle fibers of the middle portion of the tendon, while the insertional type affects the muscle fibers that attach to the lower portion of the heel.

In terms of treatment, the concept of “RICE” as discussed in previous columns, applies to this type of injury. Rest, Ice, Compression, and Elevation of the Achilles tendon can be useful to relieve inflammation and pain. Physiotherapy treatment may also be beneficial in order to improve range of motion, strength, and further reduce pain and inflammation. Your physiotherapist may prescribe exercises designed to stretch the calf muscles and improve strength. Research has shown that performing specific eccentric exercises (strengthening while lengthening the muscle) is effective in the treatment of Achilles tendinitis. In addition, orthotics and supportive footwear often help to relieve pain by correcting poor foot mechanics. Please consult with your health care provider to determine which treatment options would be appropriate for you.



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De Quervain's Tenosynovitis

De Quervain's tenosynovitis is an inflammatory condition that affects the thumb. More specifically, the condition involves inflammation of the lining of the sheath (synovium) that surrounds two tendons of the thumb: Abductor Pollicis Longus and Extensor Pollicis Brevis. The inflammation prevents the tendons from gliding smoothly through a tunnel located on the thumb side of the wrist. When the synovium of these tendons becomes inflamed friction occurs with certain thumb and wrist movements, which ultimately causes pain and discomfort.

This condition is typically caused by repetitive movements and overuse. It can also be associated with pregnancy and rheumatoid disease. Prevalence of this condition is 0.5% for men and 1.3% for women among adults.

Symptoms of De Quervain's tenosynovitis are pain over the thumb side of the wrist, either gradual or sudden in nature. Grasping, pinching, or gripping objects with the use of the thumb may aggravate the pain. Swelling and inflammation may occur over the base of the thumb at the wrist.

To diagnose this condition the Finkelstein test is often performed. This test involves placing the thumb across the palm and then making a fist with the fingers over the thumb. The wrist is then bent toward the little finger. If pain is reproduced at the thumb side of the wrist, the test is considered to be positive.

Treatment may include the use of a thumb brace or splint, rest, modalities performed by a physiotherapist to reduce pain and inflammation, and specific exercises to improve function. Repetitive thumb and wrist movements should be avoided as much as possible, as well as forceful or painful movements. Please consult with your health care provider to determine the best treatment options for your condition.



Management of Gout

Gout is a painful inflammatory condition caused by an increase in uric acid levels that result in the deposit of monosodium urate crystals in specific joints of the body. Uric acid is formed when purines (molecules containing nitrogen) are metabolized (broken down), which then combine with sodium in the body to form urate crystals. When urate levels in the blood reach 6.8 mg/dL there is a greater likelihood of the crystals forming and depositing in specific joints, causing pain, swelling, inflammation, and redness. If left untreated over time, these crystals can form larger lumps called tophi, which can lead to damage of the joint. Symptoms of gout include rapid onset of pain, usually during the night, with pain reaching its maximum within 6 to 12 hours of onset. Typically gout affects the big toe at the metatarsophalangeal joint, however, joints of the foot, ankle, knee, hand, and wrist can also be affected. Initial episodes of gout can be separated by years, but if left untreated episodes may become more frequent.

Gout typically occurs in men more than women, with the average onset being between the ages of 40 and 60. Medical conditions such as obesity, high blood pressure, diabetes, and reduced kidney function are associated with the onset of gout. In addition, medications such as diuretics, anti-hypertensives, and lipid lowering drugs can affect kidney function, and therefore alter the mechanism in which uric acid is broken down.

Diet can also play a role in the onset of gout. Research has shown that foods rich in purines are associated with increases in uric acid levels in the blood. Examples of purine-rich foods include: beef, pork, lamb, veal, organ meats (i.e. liver, heart), tuna, halibut, herring, sardines, shrimp, lobster, scallops, beer, wine, asparagus, cauliflower, beans, lentils, and spinach. Interestingly, consumption of cherries has been linked to lower uric acid levels.

The diagnostic gold standard for gout is joint aspiration, where a needle is inserted into the affected joint to draw out synovial fluid. The fluid is then analyzed for the presence of urate crystals. In addition, blood tests can also be performed to determine the levels of uric acid in the blood, however, elevated levels of uric acid can exist without the presence of any symptoms. Diagnostic imaging, such as CT, MRI, and ultrasound can also be used to determine the if tophi are present in chronic cases of gout.

Your doctor may prescribe certain medications that can help to reduce uric acid levels and inflammation. Certain NSAIDs (nonsteroidal anti-inflammatory drugs) are often prescribed at the onset of the symptoms, however, other medications that also help to reduce uric acid levels and inflammation may also be prescribed. Please consult with your physician to determine which medication(s) would be most effective for your condition. In terms of non-pharmacological treatment, rest, ice, and elevation are often helpful in reducing your symptoms. Your physiotherapist may also use modalities such as ultrasound or laser in the acute phase. Range of motion, strengthening, and/or stretching exercises of the affected joint can be performed between flare ups to maintain function. If your ability to walk is compromised due to pain, your physiotherapist may also recommend a gait aid, such as a cane, to prevent you from developing poor gait patterns. Please consult with your doctor and physiotherapist to determine the best treatment plan for you.



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Muscle contusion injuries

With fall approaching, contact sports such as hockey are well underway in Kelowna. Increased sports participation also coincides with an increase in injuries, most often musculoskeletal in nature. The most common cause of soft tissue injuries in contact sports are muscle contusions and strains. A contusion is the result of a direct, blunt force, blow to an area of the body (typically a limb) that can cause damage to muscle fibers. In hockey, these types of blows may be due to contact with another player (usually knee-on-knee collisions), or slashes with a hockey stick. Symptoms of a contusion can include localized pain at the site of the blow, swelling, pain with movement, limited range of motion, and sometimes a palpable mass.

A contusion involves a partial rupture of the muscle(s), leading to the rupture of the capillaries (blood vessels), which then leads to increased bleeding. A hematoma (a collection of blood outside of the blood vessels) can then develop, as well as swelling and inflammation. Despite the damage to the tissue, the affected muscle is still able to function to some degree. The healing process involves the formation of scar tissue and the regeneration of muscle tissue.

There have been numerous studies published over the course of several years that have investigated the best treatment approaches for contusions. Immobilization (or rest) of the affected muscle has been of interest to researchers for years. As it turns out, recent research suggests that the length of time a muscle is immobilized is a key factor in the healing process. Several animal and human studies have now indicated that a short period (24-48 hours) of immobilization immediately following a contusion injury allows the scar tissue connecting the muscle fibers to gain enough strength to withstand future muscle contractions in order to prevent re-rupture. Forms of immobilization may include taping, bracing, or the use of crutches for lower limb injuries. Furthermore, researchers emphasized that long-term immobilization should be avoided in order to promote return to motion and activity.

After the short period of immobilization, gradual movement of the injured area should be started within pain tolerance. Several studies suggest that this early mobilization following a short period of rest plays a great role in helping the muscle fibers to regenerate.

In addition, most people are familiar with the "RICE" principle, which stands for Rest, Ice, Compression, and Elevation. As you may have guessed, the immobilization research above can be summarized by the concept of "rest". Ice, compression, and elevation are also methods that help to limit the bleeding at the injury site. Research suggests that the application of ice causes short term vasoconstriction and decreased blood flow, but does not have any long term vascular effects. Therefore, applying ice immediately following a contusion injury has the greatest therapeutic effects. Compression of the area and elevation can help to decrease subsequent swelling to the injured muscle tissue.

If you have sustained a contusion or muscle injury please consult a health care practitioner to determine the best course of treatment for your condition. The above information summarizes some of the current research on muscle contusions, however, healing time and specific treatment protocols will vary by patient and severity of the injury.



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About the Author

Kristi Scott, B.Sc., M.Sc.P.T., CAFCI

Kristi is a Registered Physiotherapist. She joined her mother, Shirley Andrusiak, at Guisachan Physiotherapy after graduating from the Masters of Science in Physical Therapy Program at the University of Alberta in 2010. She also holds an Undergraduate Bachelor of Science Degree from the University of Victoria. Since graduating Kristi has completed numerous continuing education courses including manual therapy, vertigo, sport first responder, and golf related rehabilitation.  She has also completed her training with the Acupuncture Foundation of Canada Institute, and is certified to perform acupuncture, holding a designation of CAFCI.

Kristi brings an energetic, exercise based approach to her practice. She focuses on client centered care, education, exercise prescription, and manual therapy techniques. 

You can contact Kristi by email at [email protected]

 

 




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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet presents its columns "as is" and does not warrant the contents.


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