Achilles Tendinitis

Subjective:

The patient will complain of heel pain or pain in the lower calf. The problem is common in track and field sports, dancers, and not uncommon in the majority of sports.

Assessment:

There will be improved ability to do pain-free, standing toe raises.

Light Treatment Plan:

Acute conditions can be treated with a total dose of 50 to 600 joules, with the primary focus being the site of the tendon strain, followed by painting over the general area. Treatment can be given every two to three days, decreasing treatment frequency as the condition heals. Direct the photons from posterior to anterior as well as from a lateral and medial position and at an anterior angle to the tendon to infiltrate its frontal aspect. If the patient has been treated surgically, treat in a similar manner as soon as possible, even daily, until swelling and pain have decreased.

Adjunctive Treatment Plan:

When the tendon has healed and the patient can walk pain-free, then gentle stretching of the calf but not the tendon should begin. Wearing heel lifts or high heels can reduce strain on an injured Achilles tendon. Reserve stretching of the tendon and gentle strengthening until the Achilles has fully healed and exercise can be performed without pain. Taping of the tendon can help stabilize the weakened tissue.

Anterior and Posterior Cruciate Ligament Injury

Subjective:

The patient often complains of a knee “popping,” “giving out” or becoming weak. There may be reports of a “click” or a straining sensation in the knee while playing sports that require “cutting” or jumping. The patient may be limping and usually complains that the knee is painful, stiff, and swollen. The severity of the subjective complaints is usually proportional to the degree of ligament strain or rupture.

Assessment:

Improvement will show as decreased pain and swelling, with improved range of motion. In milder cases, as symptoms improve, there will be less instability with the Lachman and Drawer tests.

Light Treatment Plan:

Acute conditions can be treated with a dose of 25 to 300 joules. Only titrate if improvement is evident with a slow increase in dose. The treatment can be divided into four to five entry points on the knee joint, directed along the joint line, at the posterior, medial and lateral aspects of the knee as well as lateral and medial to the patella. Keep the light in one position, if possible, at each point, to increase the depth of penetration. Add painting over the knee if pain covers a broad area, or if using a high power device. Treatment can be given daily for up to five days, followed by decreasing frequency as long as progress is maintained.

Adjunctive Treatment Plan:

If the knee cannot be flexed or extended, the condition should be assessed by an orthopedic specialist. Straight-leg-raising exercises, with the knee in a gently extended position, and, when pain-free, gentle use of the stationary bike, can be used to tone the quadriceps. Begin additional strength training as soon as possible, teaching the patient unloaded, isometric strengthening exercises before progressing to loading and bending the knee. Strength and agility must be attained before the patient can engage in more vigorous activities. Ice/heat, taping or a knee brace can support the injury during the acute stage. Serious ruptures usually need to be surgically repaired.

(TMJ)

Calf Strain

Subjective:

There is pain in the gastrocnemius or soleus muscles usually brought on by explosive exercise or excessive stretching. The patient, in moderate cases, may exhibit a limp and have difficulty dorsiflexing the ankle due to spasm.

Assessment:

There will be a return to pain-free range of motion and normal strength in plantar flexion.

Light Treatment Plan:

An acute calf strain can be treated with a treatment dose of approximately 50 to 600 joules. This can be administered to tender points of about 10 to 25 joules over the most painful points, followed by painting over a larger muscle area. Usually, this problem is self-limiting and treatment two to three times per week for one to two weeks will be sufficient. If the strain looks severe, be certain that an Achilles tendon tear is not present.

Adjunctive Treatment Plan:

Begin self-help passive stretching as soon as it is comfortable. Do not encourage vigorous activity until the muscle has healed well.

Hamstring Strain and Tendinitis

Subjective:

There is tenderness of the proximal or distal insertion of one of the hamstring muscles of the posterior thigh. If it is a muscle strain, the pain will be more toward the middle of the posterior thigh.

Assessment:

With improvement, there will be decreased tenderness on palpation and increasingly pain-free activity.

Light Treatment Plan:

The hamstring bursa or tendon can be treated with a dose of about 25 to 200 joules. Following this, tender points can be treated or the area can be painted with approximately 10 to 50 joules. The pain is often significantly reduced after two to five treatments in the acute stage, slightly more with chronic conditions.

Adjunctive Treatment Plan:

Stretching the hamstring with the leg slightly adducted or abducted, depending on the muscle involved, can improve flexibility in the medial and lateral compartments. Use of ice/heat for five minutes, five times per day can help in the acute stage of injury.

Hip Sprain

Subjective:

Pain will be felt in the middle of the groin and may radiate to the thigh or knee. In many ways, this condition may resemble a pubic sprain, groin strain, or hip arthritis. However, unlike with arthritis, there may be an acute incident, involving an extreme hip extension or flexion precipitating this injury. Note also that hip arthritis rarely occurs in patients under 50 years old.

Assessment:

Treatment will create a rapid decrease in symptoms.

Light Treatment Plan:

Treat with 50 to 600 joules directly over the anterior acetabulum. Posterior treatment of the acetabulum can be accomplished by treating the sciatic notch and aiming the photon stream toward the hip socket. Treatment two times per week for one to two weeks is often sufficient for a mild to moderate injury.

Adjunctive Treatment Plan:

Gentle active range of motion can be encouraged but extreme passive or active range of motion should not be performed until the joint has fully healed. Strengthening of the hip muscles is imperative.

Metatarsalgia—Morton’s Neuroma

Subjective:

Many patients present with an intermittent dull ache, cramping, numbness or burning, and occasional shooting pain in the plantar aspects of the metatarsal interspaces. Symptoms usually worsen with weight-bearing activity and improve with rest. In chronic cases of Morton’s Neuroma, a lump of scar tissue will form and there is a palpable mass under the ball of the foot, which will be painful when weight is applied to the metatarsal heads. Pain can also be increased on palpation over the metatarsal heads or with a range of motion.

Assessment:

With treatment, there will be decreased pain, numbness, and cramping, and improved functional activities.

Light Treatment Plan:

Acute and chronic conditions can be treated with a dose of 50 to 300 joules. This can be directed at the interdigital nerves between the metatarsal heads.

Adjunctive Treatment Plan:

It can be helpful to alternate ice/ heat to control inflammation and pain. Referral to a podiatrist orthopedic doctor for orthotics, injections, or surgery may also be necessary if there is no improvement.

Knee Meniscus or Ligament Sprain/Strain

Subjective:

The patient will complain of pain deep inside the knee and often recall an instance of a feeling that something snapped or strained.

Objective:

When the medial and/or lateral knee joint becomes inflamed due to strain or tearing, the knee will swell within the first few hours thereafter and can stay swollen for days to weeks, depending on the severity of the strain. The knee may also feel weak like it is going to buckle or lock into one position. An MRI will usually improve the accuracy of this diagnosis. Always test for damage to the anterior and posterior cruciate ligaments as the two syndromes can occur simultaneously.

Assessment:

There will be less swelling and increasingly pain-free range of motion with an improved sense of stability and strength.

Light Treatment Plan:

Acute conditions can be treated with a dose of 25 to 100 joules. In some cases, up to 600 joules per session will be needed. Only increase the dosage if the condition shows improvement with each gentle titration. This can be directed to the medial and lateral joint line, the posterior knee,
and points just lateral and medial to the patella. Keep the light in one position at each point, if possible, to increase the depth of penetration. Add painting all over the knee if swelling is present. Treatment can be given daily for up to five days, decreasing frequency as long as progress is maintained.

Adjunctive Treatment Plan:

If the knee cannot be flexed or extended, an orthopedic specialist should assess the patient immediately. Institute straight leg raising exercises with the knee in a gently extended position, and do not add knee flexion until it is comfortably tolerated and only in the subacute phase. Taping is important to stabilize the joint. Once the knee is stable, very gentle joint mobilization may improve mobility if there is a reduced range of motion.

Kneecap and Quadriceps Tendinitis

Subjective:

This strain involves the quadriceps muscles and often includes the rectus femoris, vastus lateralis, vastus medialis, and the vastus intermedius. This muscle group becomes inflamed at their insertion on the superior or inferior patellar regions. Pain can be felt when the superior or inferior end of the patella is touched, walking up and down stairs, or performing any repeated knee flexion and extension. There may also be redness and swelling in the area.

Assessment:

There will be decreasing pain and swelling and increased ability to engage in functional and athletic activities.

Light Treatment Plan:

Treat with 25 to 200 joules directly over the inflamed tendon/ligament, angling the probe posteriorly, medially and laterally to bathe all sides of the knee in photons. Treatment is usually effective when provided one to two times per week; more frequent sessions can be helpful in the most severe cases. Often two to ten treatments are necessary depending on the chronicity of the condition.

Adjunctive Treatment Plan:

Hip extension stretching can be helpful, if appropriate, adding strengthening exercises as rehabilitation progresses. It can be helpful to use alternate ice/heat to control inflammation and pain. If the problem persists after appropriate therapy, consider a referral to an orthopedic specialist.

Peripheral Neuropathy (PN)

Subjective:

Symptoms may include numbness, loss of balance, burning, tightness, hypersensitivity to touch, and motor weakness in the feet and/or legs.

Assessment:

A small percentage of patients will achieve complete remission after 4 to 12 sessions, but most will get temporary relief for 1 to 5 days.

Light Treatment Plan:

Start with 10–100 joules per foot and increase dosage if treatment is well tolerated. PN is difficult to treat because some patients become more symptomatic after 25 joules of treatment and others feel relief when they receive more than 500 J per foot, for a total of more than 1,000 J! Spend 2/3 of the time treating the most symptomatic points on the bottom of the foot, followed by painting. Spend 1/3 of the time treating the top of the foot or the popliteal fossa to stimulate the popliteal artery.

Adjunctive Treatment Plan:

In general, optimal weight, a regular exercise program, a balanced diet, nutritional supplements, and limiting alcohol consumption can reduce symptoms. Some physicians have found that topical and oral L-Arginine can be of benefit. Nutritional support often involves a multivitamin and mineral formula with Alpha Lipoic Acid, L-carnitine, Benfotiamine, B vitamins, and other nutrients.

Plantar Fasciitis

Subjective:

The typical pain pattern is sharp pain along the middle to posterior arch of the sole of the foot. It may occasionally occur with a heel spur. Patients complain of plantar pain, particularly with the first few steps in the morning or after periods of inactivity. Excessive weight, pregnancy, repeated damage
from jumping and other high impact activities, and flat feet can be causative.

Assessment:

Treatment often results in a slow, steady decrease in pain and improved ability to engage in impact activity.

Light Treatment Plan:

Start with 25–100 joules and titrate up slowly if there is an improvement in symptoms after each session. Half of the treatment should be focused on the painful points in the plantar fascia with the other half of the joules utilized painting over the symptomatic area. Begin treating three times per week and decrease frequency as symptoms improve.

Adjunctive Treatment Plan:

During the acute phase, the patient should use ice or ice/heat on a regular basis. Taping and orthotics can be helpful. The patient should focus on non-weight bearing activities such as swimming and bicycling. In the subacute phase, regular stretching of the sole of the foot and Achilles can be valuable. As the plantar fascia heals and to reduce scar tissue, massage of the plantar fascia can be quite helpful. If conservative therapy is not successful, referral to a podiatrist or orthopedic specialist is necessary.

Restless Leg Syndrome or Leg Cramps

Subjective:

Patients complain of involuntary sudden movement of the legs. In many cases, patients may be unaware of having Restless Leg Syndrome (RLS) until it is brought to their attention when they kick a companion while sleeping. Leg cramps are also usually present.

Assessment:

Patients will report a decrease of involuntary kicks while sleeping and/or have fewer cramps.

Light Treatment Plan:

Treat trigger, tender or acupuncture points in the low back, hip, and lower extremity with 10 to 25 joules per point. Treatment can be applied two times per week for two to three weeks.

Adjunctive Treatment Plan:

Regular gentle leg and foreleg/calf stretching is vital. Sometimes stretching after heat can improve the effectiveness of the stretching. Make sure the patient has good nutrition and proper intake of minerals.

Shin Splints

Subjective:

The patient complains of pain along the medial aspect of the tibialis anterior and, in many cases along the anterolateral tibia, usually following an increase in jogging or hiking prior to the onset of symptoms.

Assessment:

Pain-free walking and then jogging is a sign of tissue healing.

Light Treatment Plan:

Acute conditions of shin splints can be treated with a total average treatment dose of 25 to 200 joules. This can be administered to tender points with 10 to 25 joules per point followed by painting the surrounding area.

Adjunctive Treatment Plan:

Make sure that the patient has good lower extremity biomechanics and good athletic shoes. Begin gentle strength training to the anterior compartment muscles as soon as it is comfortable and add stretching and massage once the tissue is in the subacute stage.

Sprained Ankle

Subjective:

Ankle pain with stiffness.

Assessment:

There will be an increased range of motion, less pain, and decreased swelling.

Light Treatment Plan:

A sprained ankle can be treated with a total average dose of 50 to 300 joules. This can be administered to the local area of the sprain with approximately 5 to 15 joules per point, especially on the lateral aspect, followed by painting over the whole ankle. Treatment can be given every two to three days for one to three weeks or until the condition is healed.

Adjunctive Treatment Plan:

A strength and conditioning program can be helpful. Encourage the patient to warm up before practice or competition and use tape to stabilize the ankle. It may be important to use an ankle brace and supportive shoes in some cases. If the condition becomes chronic or the patient is a competitive athlete, use of a balance board and other ankle exercises to increase strength, balance, and proprioception may be indicated.

Tensor Fascia Lata and Iliotibial Band Syndrome

Objective:

The patient complains of pain above or below the greater trochanter. It may present as a point of pain or mimic sciatica and radiate from the lateral buttock into the lateral knee. This is a common problem in runners and other athletes, but can also be associated with an earlier bout of sciatica or in out-of-shape patients who do not engage in regular stretching.

Assessment:

Treatment should result in less pain on palpation, increased flexibility, improved range of motion, and a return to pain-free activity.

Light Treatment Plan:

Acute conditions can be treated with a dose of 25 to 50 joules. In some cases, if the patient tolerates the treatment well, increasing to 100–300 joules may be indicated if both conditions are present. Treatment can be administered above and below the greater trochanter and distally to the lateral condyle of the tibia. Treat each tender point with 5 to 25 joules and then paint over the entire symptomatic area.

Adjunctive Treatment Plan:

When treating athletes, it may be important to encourage them to have a coach assess their
athletic form or have a foot specialist watch their gait and lower extremity biomechanics. Myofascial or trigger point massage, self-massage with a foam roll, and spray/stretch may be added to reduce spasm and fibrous adhesions. It can be helpful to institute active stretching of abductors, within a pain-free range, once the patient’s symptoms have stabilized. Reduce activity to a level that does not generate pain and try applying ice/heat to the region of pain along the ITB or TFL to control symptoms.

Tibial or Fibula Stress Fracture

Subjective:

The patient complains of pain along the shaft of the tibia or fibula.

Assessment:

There will be pain-free walking, running, and stretching.There will be pain-free walking, running, and stretching.

Light Treatment Plan:

Acute conditions can be treated with approximately 25 to 200 joules. This can be administered at about 25–50 joules per point along the painful aspect of the tibia or fibula. Treatment can be given every one to two days until improvement is evident.

Adjunctive Treatment Plan:

Often gentle weight bearing and later strength training will help stimulate healing. Avoiding anything that aggravates the pain is very important.