Clinical cases and evidence based physio

Achilles tendon rupture rehab journey

Wed, 06 May 2026 20:47:08 GMT

What good rehab and trusting the process can look like

An achilles tendon injury is relatively common injury with options for conservative (non-operative) or operative management. It will involve a period of graded immobilisation in the early weeks and subsequently an extended period of rehab commonly extending beyond 9 months to regain higher level function and strength.

In the long term it is normal to have some strength deficits or weakness and some patients may not return to their previous level of function.

Here I wanted to detail the rehab of a patient I have been working with since last year, considerations I made and how we assessed progress and return to sport testing.

Our initial appointment consisted of goal setting and the expectations for recovery and the role each of us would play. The initial assessment looked at how he was walking, ability to use the calf in isolation, measures of calf strength and outlining the rehab plan moving forwards. Given their other interests we look at strength throughout the leg as it is important to consider deconditioning across the whole body following a period of immobilisation.

Rehab then consisted of walking retraining and use of the calf through a step, and lots and lots and lots of practice, with frequent prompts and cues initially, decreasing in frequency and a more consistent patter was achieved. This is a common issue after immobilisation in the boot even though a patient is able to fully weight bear and is important to prevent elongation of the tendon as this will compromise its functional capacity in the long term, ie it will not be able to generate force effectively through a good range of motion. Strength training involved heel raises with front foot on a step - the aiming being to encourage a drive straight up. Commonly patients will try to drive the knee forwards and drag the heel up rather than actively pushing the foot into the floor. We loaded with isometric holds and loading through range. We integrated the rest of the lower limbs with carefully perform squats and rear lunge with careful observation of avoiding dorsiflexion through us of heel wedges.

At the next appointment we continued the theme of isometric calf work combined with roll outs on a foam roller, a penguin walk for isometric calf loading in plantar flexion as he was now able to hold body weight on one leg with a neutral ankle. Previous exercises we progressed from bodyweight to extra loading

Subsequent sessions involved integration of some plyometric work with partial body weight aiming to encourage ankle and tendon stiffness along with training landing mechanics and tolerance. This then progresses to a small box jump to focus on force generation. This opens the door to combined jumps with increasing force and distance. Alongside was a program of extensive plyometrics to progress tendon tolerance and stiffness, There was a small complaint of a sense of tendon stiffness in the mornings and after a period of immobilisation - signs of a low level tendinopathy which if managed carefully are not problematic and are a sign of adaptation within the tendon to increasing demands at the upper limit of its capacity.

To increase tendon and muscle demand further progress was made with heavy isometric holds on a step. Testing strength at the 8 month stage revealed

He had regained 85% of strength of the opposite leg and was able to progress to heel raises through range with a focus on the drive up and force generation.

In the latter stages we introduced graded change of direction work with a focus on how he completed the push off step, important as this is when a lot of achilles injuries occur, This return to sport was key as it allowed him to see the goal was in sight.

Final testing of lower limb symmetry involved hop testing and agility tests. These revealed a limb symmetry of 95%. The final session outlined the need for a graded exposure to play at 100 intensity build up over a period of 3-4 weeks.

All in all a successful return to sport at the 13 month point. Key considerations from the rehab journey include exercise selection and loading, monitoring for symptoms response and responding accordingly. Understand of the use of plyometrics and getting the right entry point and how they can be progressed in terms of intensive or extensive. Functional testing is key - shows high level performance and confidence of the patient to commit to using the injured limb.

A Real Pain in the... Inguinal

Sat, 10 Jan 2026 13:04:28 GMT

Adductor Related Groin Pain

Late 20's female who complained of 4 month history of intermittent groin pain after increasing her training at CrossFit. Main problems were heavy squats, wall balls and running. She had tried resting and some sports massage but the issue persisted. There was no report of back or hip pain or a history of hip pain, no pins and needles or numbness. On examination she had excellent range of motion in the hip and was able to fully squat - this did reveal excessive hip flexion, all pain free. Isometric hold using her adductors reproduced the pain and there was tenderness at the muscle tendon junction of her adductor magnus. Testing also revealed weakness in control of her trunk and pelvis along with weakness in hip extension and abduction. Pain limited her strength in adduction. There was no muscle tightness. She was suffering with adductor related groin pain (ARGP).

A rehab plan was set up to allow continued training, albeit with some activity modifications to avoid exacerbating her pain. A graded loading programme was put in place to target her adductor complex along with lots of education and reassurance on the nature of the problem.

This nice illustration from @derek_griffin_phd that highlights the factors that can contribute to developing a tendinopathy. It will exist on a continuum from acute to chronic. The tendon continuum model describes how your tendons respond to stress across three overlapping stages: Reactive, Dysrepair, and Degenerative.

The Three Stages of Tendon Health

Reactive Tendinopathy: Think of this as a "flare-up." It usually happens after a sudden burst of unaccustomed activity (like a new workout or a sudden increase in running miles). The tendon thickens slightly to protect itself from the load; it’s painful and swollen, but the structure is still intact and can fully return to normal with a short period of rest and modified activity.

Tendon Dysrepair: If the tendon continues to be overloaded without enough rest, it moves into "failed healing." The internal structure becomes more disorganized, and the body may start growing extra blood vessels and nerves in the area to try to fix it, making the tendon more sensitive.

Degenerative Tendinopathy: This is the chronic stage often seen in older athletes or those with long-term injuries. Large portions of the tendon's fibres are now broken down or "silent," meaning they can no longer handle weight effectively. While these damaged areas may not fully heal, the healthy parts around them can still be strengthened. This summed up nicely here https://bjsm.bmj.com/content/50/19/1187 by Cook et al (2016).

The next challenge is knowing how to address it. In essence the aim is to build resilience and capacity within the tendon to tolerate higher loads through range and with greater rates of force development. The challenge is often finding the appropriate starting point and increasing loading variables but taking account of the tendon response to the new stimulus.

We were able to start with low level isometrics in a comfortable mid range progression along with core strengthening and hip extension and abduction work to address some of the imbalances found on testing. Loading duration and intensity was increased along with more challenging positions in the coming months and exposure to previously problematic movements and actions (depth of squat and a graded running programme with a focus on distance and speed).

The graphic shown opposite is a great starting point from @clinicaledge for tendon loading across the spectrum. Frequency of loading is also important with consistency of work and rest days in a ratio 1:1 or 1:2.

The Dropped Shoulder

Mon, 05 Jan 2026 18:34:02 GMT

A bit out of left field

57 yo male patient presented in their words with a ‘dropped shoulder’ on their dominant side with insidious onset and their main issue was difficulty lifting the arm overhead occurring gradually over several months. They did not report an episode of debilitating pain nor could recall any recent viral infection. Generally fit and well with a history of shoulder stabilisation on the same side many years ago and excellent recovery (able to play badminton/lift weights without issue). The patient had no red flags (night pain, recent weight loss, history of cancer, non smoker)

Examination revealed marked wasting to upper fibres of trapezius and levator scapulae with a depressed and protracted shoulder girdle. They had intact sensation and upper limb motor power along with reflexes. Neck range revealed tightness of upper trapezius and levator scapular but when shoulder position was restored it was full with no reproduction of any arm symptoms. Shoulder joint range of movement was restricted due to reduced scapula mobility, when this was restored he had full shoulder pain free range. Rotator cuff testing was intact once the scapula stabilised. There was no upper limb adverse nerve tension and thoracic outlet testing was negative.

After advising the patient of the suspected diagnosis he was referred for investigation under a shoulder specialist with scans completed of his neck, brachial plexus, axilla (armpit) and shoulder. Management was centred around information provision and prognosis, guidance on movements and support for shoulder musculature, mobility and alternative exercise movements to consider.

What is Brachial Neuritis/Parsonage Turner Syndrome

A rare neurological issue affecting the brachial plexus, the network of nerves originating in the neck and controlling the function (movement and sensation) of the arm and hand. Typically the condition involves sudden onset of shoulder pain and arm in the absence of an injury. This can last for several hours to a few weeks. It is thought to be caused by the immune system, often after a viral illness. As the pain resolves it is replaced by weakness in the affected muscles and wasting will be evident (amyotrophy) on examination, you may notice the shoulder has changed ‘shape’. Each person can be affected differently depending on the specific nerves involved and recovery can vary from person to person, most often occurring over months to years.

Pain in the initial or acute phase is continuous, severe and can be worse at night or in the evening. In some instances it can be excruciating and very debilitating. Moving out of this phase the pain often settled but some movements can be problematic/restricted or painful depending to the extend of the associated weakness. Nerves can remain more sensitised for some time and any stretch or compression can cause pain and discomfort.

Weakness then becomes the predominant issue and can range from slight to pronounced depending on the number of nerves affected. This is accompanied by muscle wasting due to lack of nerve signalling and use. Reflexes can be affected along with experiencing altered sensation (numbness/ tingling/pins and needles or hypersensitivity.

Due to the weakness people can be more prone to shoulder and neck pain, due to overload of other muscles, positional changes or stiffness due to lack of use. Some may experience issues with circulation, changes to hair and nail growth or swelling.

Some individuals recover full strength and function with most regaining 70-90% of their strength and function at the 2 year point with 10-20% being left with some residual pain, decreased exercise tolerance and strength of the affected arm. It is suggested that recurrence can range from 5-25%

Treatment from a physio perspective is aimed at ensuring this is not an alternative diagnosis (cervical radiculopathy/ rotator cuff issue, frozen shoulder, guillain-barre, thoracic outlet syndrome). This will involve referral to a specialist and consideration of imaging of the shoulder, neck and brachial plexus. The focus is then on protecting any affected joints, maintaining range of movement and strength as able, advice and guidance on the course of recovery.

More information is available at https://rarediseases.org/rare-diseases/parsonage-turner-syndrome/

https://pmc.ncbi.nlm.nih.gov/articles/PMC2926354/