Next week the patient returns and you dig out their notes in the 2 minute gap you have between patients, and with no clear plan you return into firefighting mode again and deal with whatever their concern is today. This cycle can repeat itself for several sessions with little or no progress for the patient. So what’s the alternative?

Plan, Progress, Prioritise

We should always aim to make a plan with a patient. It might need to change along the way but it’s certainly better than no plan at all! So let’s think about how this might work with our achilles tendinopathy case, we’ll also use a little evidence too…

A progressive rehab plan might look a little like this;

Stage 1 address pain – isometrics in mid-range (Cook and Purdam 2013, Rio et al. 2015), gradually increase load as tolerated. Modify training to a level where there is minimal pain (VAS 3 or below) and no reaction the next day (Silbernagel et al. 2007). Discuss tendon pain, clarify that it isn’t due to tissue damage but the tendon’s response to being overworked. Be sure to address any concerns patient has and be clear about importance of pacing to achieve the right level of load for the tendon. Decide some outcome measures e.g. VISA-A, VAS during function (e.g. Running) or patient specific functional scores, make sure they are relevant to the patient. Maybe you do choose to use massage or some hands on treatment to help the pain in this stage. If so check it’s effective by re-testing an outcome measure after (e.g. Single leg calf raise).

Adam: I recognise that picture…

Stage 2 build strength and encourage tendon adaptation – heavy slow resistance training (see pic below for details) start with 15 rep max and building up to 6 rep max (Beyer et al. 2015) based on symptom response. Plan a graded return to usual training.

Stage 3 address kinetic chain factors – altered neuromotor control in quads (Azevedo et al. 2009) or glutes (Smith et al. 2014) has been associated with achilles tendinopathy. These muscle groups assist the calf complex in absorbing load during the impact phase of running so it makes sense to strengthen them, especially if they are weak. Consider addressing posterior chain too as this assists the calf in achieving propulsion during running. Decreased knee flexor strength has been suggested as a risk factor for achilles tendinopathy in runners (Hein et al. 2013). Increased or restricted ankle dorsiflexion may also play a role. Consider assessing running gait. Has there been any recent, deliberate change e.g. Switching to forefoot strike? Are there factors we might address that could lead to additional load on the achilles?

Stage 4 progress to power and plyometric exercises – once tendon pain is stable and able to tolerate high load tests (e.g. Hopping) increase speed during calf rehab exercises and add plyometrics. Monitor symptom response. Consider long term management e.g. Once weekly strength work to maintain tendon and muscle health and function.

Stage 5 “high five” the patient, do a small victory dance and smile contentedly as you discharge them into the wild, another happy customer, no fires in sight!

In reality of course patients often don’t fit into neatly planned stages but having a rough plan, some outcome measures and ideas for progression is better than dealing with symptoms on a session by session basis. Whatever you do make sure you have something more comprehensive than just ‘continue’ in your plan!

We do also come across barriers that make treatment planning harder;

Lack of knowledge – in you don’t have sound clinical reasoning or many treatment options at your disposal you’ll likely to keep picking the same approach regardless. Reflect on areas for potential development and plan how to improve them.

Faulty assumptions – do you sometimes assume the patient wants hands on or immediate relief? Do we assume when we do this it actually works? Ask the patient their expectations of treatment and be clear on their goals.

Lack of time – this is a tricky one and undoubtedly it can affect our treatment choices. People are increasingly busy, it’s not unusual for some physios to see 10 patients before lunch with no break. Own up, have you ever made a clinical decision based on how likely it was to give you enough time for a cup of tea?! Oddly though if time is the issue why spend 20 minutes doing massage or acupuncture? I’m not anti-hands-on but it needs to be used appropriately based on the right reasoning and as part of a progressive rehab plan. It shouldn’t be used at the expense of everything else!

Patient choice/ pressure – this might be the hardest one, you want to do progressive rehab, but the patient just wants some immediate relief. Now it’s them fighting fires!

Beyond our clinical tendency to just deal with the immediate issues we can do this in our personal development and in life as a whole. If we fail to plan or prepare for things we need to adjust our expectation of how these things will go. It can be really useful to sit with a calendar in front of you and plan how you want the next 6-12 months to go. How will you deal with persistent stresses? How will you achieve your goals? Do you need to change your daily, or weekly schedule to fit things in? How can you plan to get a good work/ life balance?

So, have a think…are you a firefighter? If so put down the hose and start making some plans…

For more from Tom listen to his recent NAF Physio Podcast and check out his popular Running Repairs Course.