Case Study: Sacroiliac Joint Pain and the Rehabilitation of Achilles Tendon Repair

Introduction

Achilles tendon rupture is one of the most common tendon ruptures despite being considered the strongest tendon in the body ^{(1, 2)}. Different from any other tendon, the Achilles needs to be stiff enough to withstand several times our body weight. At the same time, elastic enough to allow for ankle movement. Its rupture is more prevalent in males but both genders are susceptible to its occurrence, particularly in the young athletic population ^{(3, 4)}.

There is some debate in the literature with regards to surgical versus conservative treatment that discussion goes beyond the scope of this case study. More importantly, there seems to be some advantages to functional rehabilitation in the first six months in comparison to traditional cast immobilisation ⁽⁵⁾. Functional rehabilitation includes early weight bearing and gradual exposure to loading. Ultimately, being able to single heel raise and single leg hop are some of the primary functions to be restored ⁽⁶⁾. Both these functions allow for participation in simple task such as walking, negotiating stairs or reaching to a higher shelf, as well as running, jumping and return to sport ⁽⁴⁾.

Case Report

Interview:

30 years old female, paediatric ICU nurse, presents herself to a Physiotherapy Private Practice 5 weeks’ post (L) Achilles tendon percutaneous repair. Initial mechanism of injury was changing in directions whilst playing Netball. Concurrently, mentioned the onset of (L) buttock pain and (L) sciatica pain as she fell onto it. Described buttock pain as generally dull but to some extent sharp with loading, aggravated by either sitting or standing, in the PNRS 6-7/10 range. The ‘sciatica’ symptoms did not pass the knee and were mostly referring to her hamstring area. Standing, walking or driving would set off the hamstring region and back of the hip. She did not report any low back pain, previous history of injuries or trauma. Generally, a healthy patient taking only Panadol and NSAIDS as required. No red or yellow flags identified.

Objective assessment:

• Wearing a moonboot with 2x 2cm heel lifts and PWB (partial weight bearing) as per surgeon’s request. Next step to remove wedges and WBAT (weight bear as tolerated).
• BMI: 27 kg/m²
• Gait: PWB with forearm crutches and moonboot, antalgic, body weight shifted to the (R) and with external rotation (L) hip
• WBLT (weight bearing lunge test) ^{(7, 8)}: 12cm (R) / -12cm (L)
• Balance: single leg standing eyes open – 3 seconds only with moon boot on.
• (L) ASLR (active straight leg raise): able to perform with excessive pelvic rotation ⁽⁹⁾.
• (L) PSLR (passive straight leg raise): refers SIJ, buttock and hamstring pain at 60 degrees ⁽¹⁰⁾.
• Pain reproduction +ve during (L): thigh thrust / distraction / sacral thrust⁽¹¹⁾
• Dynamometer (peak force):
  Knee extension sitting: 35kg (R) / 24kg (L)
  Hip abduction sidelying: 19kg (R) / 10kg (L)
  Ankle plantarflexion supine lying: 36kg (R) / 9kg (L)
• Tender on palpation of the (L) Long Posterior Sacroiliac Ligament, Sacrospinous ligament, Sacrotuberous ligament, Ischeal tuberosity and conjoin hamstring tendon.
• Body type: hypermobile

Outcome measure:

LEFS (Lower Extremity Functional Scale) – initial score 13/80

Diagnostic hypothesis and differential diagnosis

The description of buttock pain referring to the hamstring region provided by this client is described in the literature as a common feature of SIJ driven pain ⁽¹²⁾. Also, aggravating factors such as increased pain in sitting and upright loading, especially during single leg weight bearing, are suggestive of SIJ dysfunction ⁽¹⁰⁾. Even though this client used the terminology sciatica, classic sciatica symptoms are usually associated with lumbar spine pain and symptoms distal to the knee ⁽¹³⁾.

The SIJ is a force transmission area between the lower body and the trunk. An appreciation for the patients’ symptoms is biomechanically plausible in this context. Aside from the direct trauma to it, the sudden failure of the Achilles would result in strong recoil force being absorbed at the knee, hip and spine, including the sciatic nerve. The combination of events described, were likely the culprit for the peripheral sensitisation of the SIJ. In accordance to contemporary evidence behind SIJ pain, peripheral tissue sensitisation is a better explanation for symptoms experienced rather than the once assumed positional dysfunctions of the innominate and sacrum ⁽¹⁴⁾.

The objective findings were helpful in ruling out any lumbar spine disc and nerve pathology, which could trigger sciatica, SIJ and hamstring symptoms. Namely, free active and passive Lumbar spine ranges and -ve SLR. The literature reports that limited or symptomatic active range of motion for lumbar flexion and +ve SLR with the reproduction of symptoms in the first 45 degrees of flexion are common in lumbar radiculopathy ⁽¹⁵⁾. On the other hand, reproduction of symptoms with increased hip ranges is suggestive of SIJ dysfunction or lumbar facet joint syndrome.

Evidence from the literature is also available for the diagnosis of SIJ driven pain via clustering of provocative tests as proposed by Laslett, Aprill ⁽¹¹⁾, which were positive in this case. She was unable to single leg stand on the left side due to the lack of range on her ankle at initial assessment but also lack of strength in the kinetic chain. SIJ pain reproduction was achieved even when wearing her boot and using hands for balance support. Lastly, an ASLR +ve suggested SIJ peripheral sensitisation leading to altered motor control ⁽¹⁶⁾. The period of non-weight bearing protocol followed by a few weeks of partial weight bearing with a discrepancy of limb length due to moonboot height and heel raises were also relevant.

Lastly, considering the combination of findings, biomechanical and neurophysiological, affecting the entire lower limb and its kinetic chain; the Lower Extremity Functional Scale was chosen as a self-reported measurement tool.

Discussion

The main challenge in the presentation of this client was to navigate the Sacroiliac symptoms, whilst still building capacity on the Achilles tendon. The return to work time frame was 12 to 16 weeks.

Her job demands included 12 hour shifts, mostly standing, where 2 nurses were responsible for the paediatric unit. There was frequent use of stairs between the nursery and ICU and the urgent nature of the job in a delicate environment to be considered.

The needs of the Achilles tendon with regards to progressive loading and restoration of tendon capacity to withstand load, notably in single leg tasks, would most often aggravate the SIJ symptoms. Consequently, pain would inhibit activation of the whole kinetic chain and especially the calf-achilles complex ⁽¹⁷⁾. Progressive loading is regarded as best practice in the post-surgical management of Achilles rupture ^{(1, 2, 4, 5, 18)}. Considering the symptomatic ipsilateral SIJ, the use of an antigravity treadmill was very helpful in allowing controlled lower limb loading whilst still managing the SIJ symptoms. There is good evidence from the literature regarding the advantages of early loading post Achilles Percutaneous Repair ⁽¹⁸⁾. On the other hand, the literature does not provide information regarding the use of an antigravity treadmill in either SIJ dysfunction or following Achilles tendon repair. Therefore, loading was adjusted according to the patient’s symptomatic report. The patient numerical rating scale was utilised and scores above 4/10 for SIJ or Achilles related pain were used as a cut-off to either stop or decrease the loads.

The SIJ symptoms were managed with manual therapy, motor control exercises for the lumbopelvic region ⁽¹⁹⁾. Current literature expands on the role of motor control exercises in lumbopelvic pain. The use of retraining exercises is a valid strategy in addressing symptomatic individuals who have been assessed to have an impairment in that domain ⁽¹⁴⁾.

Apart from specific motor control exercises, general glute and hamstring exercises were also incorporated. The same principals utilised for exercise prescription and progression in proximal hamstring tendinopathy were used in this case ⁽²⁰⁾. Land based as well as Reformer exercises were progressed from less provocative positions with neutral hip alignment towards increased hip flexion angles and from isometric to isotonic.

Manual therapy played a vital role in addressing ankle dorsiflexion via mobilisations with movement as per Mulligan’s description ⁽²¹⁾. Local tissue peripheral sensitisation was also modulated around the SIJ, hamstring and calf via Dry Needling ⁽²²⁾.

At the end of 14 weeks of rehabilitation this patient could resume her duties as a Nurse. Her final LEFS score was 56/80, corresponding to 70% overall capacity. She was referred on for further care in NSW, where she was based. She decided to abandon social Netball.

Conclusion

The main highlight of this case was the importance of a multimodal approach and patient centred care. Time frames given were short considering the injury sustained and tissue healing times. However, with a strong emphasis in active progressive loading and a well-structured rehabilitation, this client could resume her work duties as planned. A bigger emphasis on seated calf raises could have been included in future similar presentations in the early stages to manage a symptomatic SIJ whilst still loading the Achilles tendon. She had a total of 73 interactions between supervised and unsupervised sessions over the 14 weeks’ period, yielding an average of 5.2 consults per week.

Bruno Rebello (APAM)
Physiotherapist

Featured in the Top 50 Physical Therapy Blog

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