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P: 604.873.4467F: 604.873.6211
Massage Therapists’ Association of British Columbia
Clinical Case Report Competition
Utopia Academy
November 2013
First Place Winner
Christine MiembanThe effects of neuromuscular technique on surgically
repaired Achilles tendom rupture
MTABC 2013
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Table of Contents
Acknowledgements………………………………………………………………………… 2
Abstract…………………………………………………………………………………….. 3
Introduction………………………………………………………………………………… 4
Case Subject History……………………………………………………………………….. 6
Methods……………………………………………………………………………………..8
Results……………………………………………………………………………………… 10
Discussion………………………………………………………………………………….. 14
Conclusion…………………………………………………………………………………..16
References………………………………………………………………………………...... 17
Appendix A…………………………………………………………………………………20
Appendix B………………………………………………………………………………....21
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Acknowledgements
To my case advisor, Aaron Ashe, thank you for all your help with this case study. Your insight
has been extremely invaluable to me.
To Jim Bowie, thank you for continuously sharing your knowledge with me. It has been a
pleasure working with you and learning from you.
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Abstract
Objective: To determine if neuromuscular technique (NMT) performed on the gastrocnemius and soleus complex will increase ankle dorsiflexion and decrease scar tissue adhesion in an individual with surgical reattachment of the Achilles tendon, following an Achilles tendon rupture. Background: The subject is a 37 year old, healthy and physically active male. He sustained a complete Achilles tendon rupture to his left ankle while participating in an ultimate Frisbee game in June of 2012. Surgical reattachment of the Achilles tendon was performed one day following the injury. Methods: A series of 10 treatments were performed on the subject over a 5 week period. Treatments consisted of Swedish massage, followed by treatment of the left leg utilizing NMT on the gastrocnemius/soleus complex and scar tissue on the Achilles tendon. Results: Significant increases in both passive and weight bearing dorsiflexion have been observed. An overall increase of 17 degrees in passive dorsiflexion was recorded from treatment #1 to treatment #10 with a mean increase of 2.5 degrees at the end of each treatment. Knee-to-Wall Test measurements revealed an overall increase of 4.5 cm in weight-bearing dorsiflexion, with a mean increase of 0.49 cm with each treatment. Scar tissue adhesions decreased and pliability increased over the treatment period and width measurements were found to decrease incrementally over time. Conclusion: NMT, in conjunction with remedial exercises, was determined to be an effective treatment modality in the treatment of a surgically repaired Achilles tendon following a complete Achilles tendon rupture. Key words: Neuromuscular Technique (NMT), Friction, Achilles Tendon Rupture, Achilles Tendinopathy
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Introduction
A tendon is a fibrous tissue that serves to attach muscle to bone1. The Achilles tendon is
located on the posterior leg and attaches to the posterior portion of the calcaneal bone1. It serves
as a common tendon for the gastrocnemius and soleus muscles, both of which function in plantar
flexion of the ankle1. This function is essential as it allows individuals to walk, run, jump and
stand on one’s toes.
Achilles tendon rupture occurs when the tendon itself is torn off of its attachment on the
calcaneal bone2. This tearing may occur anywhere along the tendon, as well as the
musculotendinous junction. The exact mechanism of this injury remains unclear as it tends to
occur spontaneously, particularly during sporting events or vigorous types of activities2. It is
thought that because the Achilles tendon is subject to large amounts of load in the body,
repetitive stress to this tendon causes it to be susceptible to injury3. Individuals who have
sustained this injury often describe the initial sensation as if he/she was hit or kicked in the back
of the leg, and there is often an audible sound2. The gastrocnemius and soleus muscles are
greatly affected and the individual is unable to plantar flex at the ankle. In addition, dorsiflexion
becomes limited, especially with reattachment of the tendon2. An individual is unable to
lengthen the gastrocnemius and soleus and this can ultimately affect one’s gait and ability to do
certain activities.
The injury occurs in 18 out of 100,000 people4 and often occurs in athletes between the
ages of 30 and 40 years, with a 10:1 ratio of males to females2. A recent study, conducted in
Edmonton, Alberta, Canada, determined that an average of 8.3 persons per 100,000 sustained an
Achilles tendon rupture5.
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Debate currently exists over the optimal treatment for Achilles tendon ruptures. Surgical
repair has been the preferred method, as several studies have indicated the rate of re-rupture after
surgery is low6,7. Although surgery is often the chosen method of treatment, some practitioners
argue that it is unnecessary as the risk of infection and other complications are increased.
Alternative treatments that have also been used in Achilles tendon rupture include cast
immobilization and functional bracing8. Functional braces or orthoses allow the ankle to be
locked into plantar flexion. Adjustments on the brace can be made by a physician or
physiotherapist to gradually move the ankle into dorsiflexion8. Several studies support this non-
conservative method. One such study indicated that 80% of subjects reported good to excellent
results with the use of a customized polypropylene orthosis9.
Surgical intervention is often the treatment of choice and this typically involves re-
attachment of the Achilles tendon. Following surgery, the patient is casted in a plaster and/or
fibreglass cast in a neutral position. If the patient is not casted, he/she is placed in a removable
boot with wedges under the heel to allow the ankle to rest in plantar flexion. The wedges are
progressively taken down to allow the ankle to gradually move into dorsiflexion8. Physicians
often recommend physical therapy following removal of the cast or when the ankle is able to
move into a neutral position8.
The purpose of this case study is to determine if massage therapy can increase range of
motion at the ankle joint, as well as decrease scar tissue size and adhesions, following surgical
reattachment of the Achilles tendon resulting from a complete Achilles tendon rupture. It is
hypothesized that: 1) Neuromuscular technique (NMT) performed on the gastrocnemius and
soleus complex increases dorsiflexion of the ankle and 2) NMT on scar tissue decreases
adhesions and tissue size.
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Case Subject History
The subject is a 37 year old male, who is a mechanical engineer. He currently maintains
a physically active lifestyle, which includes weight training (3-4 days/week), kite boarding (1-2
days/week), ultimate Frisbee (1 day/week) and beach volleyball (1 day/week). No other
conditions have been reported.
In June of 2012, the subject participated in a 2 day ultimate Frisbee tournament. On day
1 of the tournament, the subject reported feeling good after having played two games. During
the second game on day 2 of the tournament, the subject reported sprinting down the field and
feeling a kick in the back of his left heel, causing him to fall to the ground. He did not
experience any pain initially. He was taken to the hospital where radiographs confirmed the
complete rupture. The Achilles tendon was surgically reattached to the calcaneus the following
day. The subject was casted in dorsiflexion for one week in a plaster cast and 4 weeks thereafter
in a fibreglass cast.
Rehabilitation began after the cast was removed and entailed 3 days a week of
physiotherapy, massage therapy and athletic training. Strengthening, increasing muscle mass
and proprioceptive training were the main goals in physiotherapy and athletic training, while
treating compensatory structures and decreasing scar tissue formation were the main goals in
massage therapy. The subject continued with 3 days per week of treatments until the end of
December of that year. Despite efforts to decrease scar tissue formation, a significant amount of
scar tissue remains on the Achilles tendon. This, coupled with constant hypertonicity in the
gastrocnemius and soleus muscles, has contributed to a decrease in range of motion at the ankle
joint. Consequently, the subject has found a decrease in performance in the activities he partakes
in.
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The subject has not sought any therapy for his injury since the end of December of 2012.
He currently presents with hypertoned gastrocnemius and soleus muscles, as well as limited
dorsiflexion of his left ankle. A significant amount of scar tissue has formed around the surgical
incision, as well as on the Achilles tendon and has resulted in restrictions in movement of the
ankle. The subject continues to feel tightness in his left leg and in the area of the scar tissue and
stretches both the gastrocnemius and soleus muscles when the tightness arises.
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Methods
Assessment Tools & Protocols
Assessment took approximately 15 minutes before each treatment, and measurements
were taken before and after each treatment. Range of motion of the ankle was taken using a
goniometer with focus placed on active dorsiflexion and plantar flexion. In addition,
dorsiflexion of the ankle with weight bearing was taken using the Knee-to-Wall Test10
(Appendix A). Scar tissue widths were taken at 3 points along the scar using a skin-fold caliper
at the end of each treatment session. The first point was measured at 14.2 cm from the floor; the
second point was measured 12.2 cm from the floor; and the third point was measured 10.2 cm
from the floor. These points were determined by the top, middle and bottom of the scar tissue in
relation to the floor. Measurements for each point were taken three times and the average of
these three measurements was then recorded. Assessment also included a Manual Muscle Test
(MMT) of both the gastrocnemius and soleus muscles to gauge the muscles’ strength and
functionality11. The MMT was performed at treatments 1, 4, 7 and 10. Scar tissue adhesion and
pliability was assessed with movement in 4 directions: superior, inferior, medial and lateral12.
Treatment Protocol
The subject was treated for 60 minutes. Each treatment consisted of 20 minutes of
Swedish massage and petrissage techniques on the right leg, as well as on the gluteal group,
quadriceps, hamstrings and tibialis anterior muscles of the left leg. This was followed by 40
minutes of treatment to the posterior aspect of the lower left leg. NMT was performed on the
gastrocnemius and soleus muscles to decrease hypertonicity12. Longitudinal frictions and
bowing were performed on the Achilles tendon to further lengthen the muscles. The scar tissue
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was treated with bowing, picking up and peeling of the tissue off of the underlying structures.
Cross-fibre frictions were incorporated in treatment of the scar tissue. Three 1.5 minute sets of
frictions were performed on the tissue, with each set followed by passive stretching of the
gastrocnemius and soleus muscles. The first set of frictions involved moderate pressure while
the following two sets involved progressively deeper application of pressure. The three sets
were then repeated along the scar tissue.
The subject was advised to place ice on the left Achilles tendon over the scar after each
treatment for 10 minutes. Passive stretches for the gastrocnemius and soleus were demonstrated
and prescribed 2 times a day (once in the morning and once in the evening) and the subject was
asked to hold each stretch for 30 seconds. Eccentric heel drops, both with the knee kept straight
and with the knee bent, were prescribed to strengthen the gastrocnemius and soleus muscles13
(Appendix A). This exercise was prescribed at 2 sets of 10 repetitions each and done once a day.
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Results
Increases in range of motion, particularly with dorsiflexion, were observed. The results for range
of motion are located in Tables 1, 2 and Figures 1, 2.
The results show linear increases in dorsiflexion over the course of 10 treatments.
According to Figure 1 of the results, there are marked increases in passive dorsiflexion of the
subject’s left ankle following each treatment session. The mean increase in dorsiflexion before
and after treatment was calculated to be 2.5 degrees with an overall increase of 17 degrees in the
left ankle. Similar results are observed with dorsiflexion in weight bearing in the Knee-to-Wall
Test, pre- and post-treatment (Figure 2). The average increase in dorsiflexion between pre- and
post-treatment was calculated at 0.49 cm. Despite the small increases between the treatment
sessions, the subject made an overall increase of 4.5 cm. The end measurement for the Knee-to-
Wall Test was 11.7 cm.
RANGE OF MOTION PRE-‐TREATMENT RANGE OF MOTION POST-‐TREATMENT Treatment # Dorsiflexion Plantar Flexion Treatment Dorsiflexion Plantar Flexion
1 R 16 o R 48 o 1 R 20 o R 48 o L 3 o L 48 o L 6 o L 49 o
2 R 20 o R 48 o 2 R 20 o R 48 o L 5 o L 48 o L 10 o L 50 o
3 R 20 o R 48 o 3 R 20 o R 48 o L 3 o L 48 o L 10 o L 50 o
4 R 20 o R 50 o 4 R 20 o R 50 o L 10 o L 50 o L 13 o L 50 o
5 R 20 o R 48 o 5 R 20 o R 50 o L 12 o L 50 o L 15 o L 50 o
6 R 18 o R 48 o 6 R 20 o R 49 o L 14 o L 47 o L 16 o L 50 o
7 R 18 o R 49 o 7 R 18 o R 49 o L 14 o L 48 o L 16 o L 50 o
8 R 18 o R 48 o 8 R 18 o R 50 o L 15 o L 50 o L 18 o L 50 o
9 R 18 o R 50 o 9 R 20 o R 50 o L 18 o L 50 o L 18 o L 50 o
10 R 20 o R 49 o 10 R 20 o R 50 o L 19 o L 50 o L 20 o L 50 o
Table 1: Range of motion measured pre-‐ and post-‐treatment
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Figure 1: Progress in dorsiflexion of left ankle pre-‐ and post-‐treatment
KNEE TO WALL TEST Treatment
# Pre-‐Treatment
(cm) Post-‐Treatment
(cm) 1 R 12.2 12.8
L 7.2 7.6 2 R 12.4 12.4
L 7.6 8.0 3 R 12.3 12.3
L 7.5 9.2 4 R 12.4 12.3
L 9.3 9.6 5 R 12.4 12.4
L 9.6 10.0 6 R 12.1 12.1
L 10.1 10.4 7 R 12.2 12.2
L 10.0 10.6 8 R 12.2 12.2
L 10.5 10.7 9 R 12.4 12.4
L 11.0 11.6 10 R 12.6 12.6
L 11.7 11.7 Table 2: Measurements of Knee to Wall Test pre-‐ and post-‐treatment
0 10 20 30 40 50
1 2 3 4 5 6 7 8 9 10 Range of M
oCon
(o)
Treatment #
Dorsiflexion Measurements of LeP Ankle
Pre-‐Treatment Post-‐Treatment
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Figure 2: Trend of Knee to Wall Test measurements pre-‐ and post-‐treatment
Decreases in scar tissue size are seen in the following Table 3 and Figure 3. Images of the left
Achilles tendon are seen in Appendix B.
Each of the three measured points in relation to the scar tissue reported a total decrease of
8 mm, 4 mm and 5 mm, respectively. Furthermore, tissue pliability increased while adhesion
decreased. Movement of the scar tissue in 4 directions (lateral, medial, superior and inferior)
increased and the therapist was able to lift the scar tissue off the Achilles tendon.
SCAR TISSUE WIDTH MEASUREMENTS
Treatment # Post-‐Treatment (mm)
1 36 33 33 2 36 33 33 3 35 32 32 4 35 32 32 5 34 32 30 6 33 30 30 7 32 30 30 8 32 30 29 9 30 29 29 10 28 29 28
Table 3: Measurement of scar tissue width pre-‐ and post-‐treatment
0 2 4 6 8
10 12
1 2 3 4 5 6 7 8 9 10 Measuremen
t (cm
)
Treatment #
Knee-‐to-‐Wall Measurement of LeP Ankle
Pre-‐Treatment Post-‐Treatment
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Figure 3: Scar Tissue Measurements post-‐treatment
No changes were seen in the MMT of the gastrocnemius and soleus muscles. A grade of
5 for both muscles was recorded at treatments 1, 4, 7 and 10.
0
10
20
30
40
1 2 3 4 5 6 7 8 9 10 Measuremen
t (mm)
Treatment #
Scar Tissue Measurements Post-‐Treatment
PosiCon 1 PosiCon 2 PosiCon 3
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Discussion
Massage therapy, including Swedish and NMT, were effective in increasing range of
motion and decreasing scar tissue adhesions after an Achilles tendon rupture and surgical repair.
Limited literature exists in regards to Achilles tendon rupture and NMT. The results from this
study are consistent with literature on the effects of neuromuscular technique on increasing range
of motion and decreasing scar tissue adhesions14,15. One such study’s results indicated that the
use of frictions increased the pliability of scar tissue due to the mechanical forces that induce
change at the cellular level15. In addition, massage therapy combined with remedial exercises,
are consistent with literature on the use of eccentric exercises following repair of an Achilles
tendon rupture13,16,17.
The subject reported a noticeable decrease in overall “tightness” of the gastrocnemius and
soleus muscles and found an improvement in function while participating in physical activities.
Furthermore, the restrictions around the scar tissue that the subject had experienced previously
have diminished. The subject also found the remedial exercises to be of benefit, particularly on
days between treatments.
Physical therapy has often been chosen by physicians for rehabilitation of Achilles
tendon rupture and repair. This study has given valuable information regarding massage therapy
in the treatment of an Achilles tendon rupture. The results suggest that NMT effectively
increased range of motion and decreased scar tissue adhesions. This information is beneficial for
massage therapists as many therapists utilize NMT in the treatment of many pathologies. Since
there is limited literature regarding massage therapy and Achilles tendon rupture and repair, the
results of this study are encouraging for massage therapists and massage therapy provides an
excellent adjunct to current therapies for this particular injury.
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Despite the overall effectiveness of the case study, there are a number of limitations that
need to be addressed. As this study focused on the results of one individual, it is important to
note that the results seen in this study may not be representative of a larger population and
therefore, a future study should include a larger sample size. The efficacy of the massage
treatments versus the efficacy of the remedial exercises are yet to be determined, as it is difficult
to say whether one or the other, or a combination of both, contributed to the success of the study.
As such, it may be of benefit to consider utilizing massage therapy or remedial exercises rather
than a combination of the two when conducting a study. This may aid in determining what the
results are attributable to. Furthermore, this study only takes into account treatment of the
Achilles tendon rupture and repair in a chronic state. Perhaps the results would differ if
treatment was provided closer to the date of injury and repair, rather than a year following the
injury.
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Conclusion
The effectiveness of neuromuscular technique on increasing range of motion in the ankle,
as well as decreasing scar tissue size and adhesions, is strongly evident in this study. The results
show a significant increase in dorsiflexion and slight decreases in scar tissue.
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References
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Jersey: John Wiley & Sons, Inc.; 2012.
2. Brukner, P. and Khan, K. Clinical Sports Medicine. 3rd ed. Australia: McGraw-Hill; 2006.
3. Nandra, R., Matharu, G. and Porter, K. Acute Achilles tendon rupture. Trauma. 2011; 14(1):
67-81.
4. Aktas, S., Kocaoglu, B., Nalbantoglu, U., et al. End-to-End Versus Augmented Repair in the
Treatment of Acute Achilles Tendon Ruptures. The Journal of Foot & Ankle Surgery. 2007,
September; 46(5): 336-340.
5. Suchak, A., Bostick, G., Reid, D., Blitz, S., Jomha, N. The Incidence of Achilles Tendon
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6. Nyyssonen, T., Saarikoski, H., Kaukonen, J., et al. Simple end-to-end suture versus
augmented repair in acute Achilles tendon ruptures: a retrospective comparison in 98
patients. Acta Orthop Scand. 2003, April; 74(2): 206-208.
7. Bhandari, M., Guyatt, G., Siddiqui, F., et al. Treatment of acute Achilles tendon ruptures: a
systematic review and meta-analysis. Clin Orthop. 2002, July; 431: 190-200.
8. Khan, R., Fick, D., Keogh, A., Crawford, J., Brammar, T., Parker, M. Treatment of Acute
Achilles Tendon Ruptures: A Meta-Analysis of Randomized, Controlled Trials. Journal of
Bone and Joint Surgery. 2005, October; 87(10): 2201-2210.
9. McComis, G., Nawoczenski, D., De Haven, K. Functional bracing for rupture of the
Achilles tendon: Clinical results and analysis of ground-reaction forces and temporal data.
Journal of Bone and Joint Surgery. 1997, December 1; 79(12): 1799-1808.
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10. Konor, M., Morton, S., Eckerson, J., Grindstaff, T. Reliability of Three Measurements of
Ankle Dorsiflexion Range of Motion. The International Journal of Sports Physical Therapy.
2012, June; 7(3): 279-287.
11. Kendall, F., McCreary, E., Provance, P., Rodgers, M., Romani, W. Muscles: Testing and
Function with Posture and Pain. 5th ed. Baltimore: Lippincott Williams & Wilkins, 2005.
12. Rattray, F., Ludwig, L. Clinical Massage Therapy: Understanding, Assessing and Treating
over 70 Conditions. Elora, Ontario: Talus Inc.; 2000.
13. Grigg, N., Smeathers, J., Wearing, S., Urry, S. Tendon rehabilitation: Isolated eccentric
loading invokes a greater reduction in Achilles tendon thickness than concentric loading.
Journal of Medicine and Science in Sport. 2008, January; 12: S20.
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Tendonopathy. Clinical Journal of Sport Medicine. 2004; 14: 40-44.
15. Thuzar, S., Bordeaux, J. The Role of Massage in Scar Management: A Literature Review.
Dermatologic Surgery. 2012, March; 48: 414-423.
16. Henriksen, M., Aaboe, J., Bliddal, H., Langberg, H. Journal of Biomechanics. 2009,
December 11; 42(16): 2702-2707.
17. Fahlstrom, M., Jonsson, P., Lorentzon, R., Alfredson, H. Chronic Achilles Tendon pain
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http://sportspodiatryinfo.files.wordpress.com/2010/02/lunge-test4.png
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Appendix A
Knee-to-Wall Test This test is also known as the Weight Bearing Lunge Test (WBLT). A tape measure is placed on the floor with the wall measured at 0 cm. The subject is then asked to place the tested foot next to or on top of the tape measure. A lunge is then performed with the second toe, centre of heel and knee perpendicular to the wall and the heel firmly on the ground18. The subject lunges forward so that the knee touches the wall and the heel is still in contact with the ground. If the knee cannot touch the wall, the subject moves the foot closer to the wall and perform the lunge until contact with the wall occurs. Measurement is taken from the wall to the first toe.
Figure A: Final position of test19
Figure B: Patient positioning during the test20
Eccentric Heel Drop Exercises
Figure C: Positioning for heel drop exercises21
A - The patient stands on the edge of a platform and stands on tips of toes. B - The patient then lowers one heel with the knee straight. C - Steps A & B are repeated with the knee bent after completing 10 repetitions with the knee straight.
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Appendix B
Treatment #1
Treatment #4
Treatment #7
Treatment #10