E STÁNDARES DE P ROGRAMACIÓN

The Achilles tendon, also known as the tendo calcaneus, is formed by the soleus and gastroc-nemius musculature and is often a site of irrita-tion in the athletic and recreairrita-tional populairrita-tion.

The broad aponeurosis is flatter at the muscu-lotendinous junction and then becomes more cordlike as it approaches the calcaneus. There-fore, a strumming palpation can be performed to assess its integrity proximally. However, above the heel, a pincing and sliding motion up and down the tendon can be used to assess both the tendon and its sheath for the presence of tissue lesions.

Origin: Inferior fibers of the gastrocne-mius and soleus musculature Insertion: Calcaneus

Action: Plantar flexes and stabilizes the ankle

Gastrocnemius (medial head)

Flexor retinaculum

Gastrocnemius (lateral head)

Achilles tendon Soleus

Superficial posterior

E6296/Speicher/Fig. 05.06/532057/JG/R1

Palpation Procedure

• The patient should be positioned prone with the knee flexed and ankle bolstered to relax the triceps surae complex.

• Start palpation at the posterior calcaneus and work proximally to the tendinous aspect of the tissue above the heel. Once the tendon is gained, apply light pincing coupled with a slid-ing motion up and down its sheath and tendon.

• To evaluate the tendon’s glide in its sheath, apply slight pressure to both sides of the tendon while the patient plantar flexes the ankle.

• Once the tendon flattens proximally, it can be strummed across its expanse.

• Note the location of any tender points or fasciculatory response of the tendon and its attachments.

• Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred.

PRT Clinician Procedure

• The patient is prone with the knee flexed to approximately 20 to 30°.

• Place the ankle into marked plantar flexion on your thigh or on a bolster.

• Using the near hand, place one or two fingers over the tender point.

Achilles tendon palpation procedure.

• Use the fingers of your far hand to translate the posterior calcaneal fascia and tendon sheath cephalad while compressing the calcaneus downward.

• Distract the talocrural joint caudally, while simul-taneously compressing and rotating the hind-foot downward with the palm of the treatment hand into the talocrural joint. This movement can be facilitated by either pulling the thigh away from the knee or using your far hand.

• Evert or invert the ankle with the far hand based on the location of the lesion.

• Apply calcaneal rotation with the far hand to fine-tune.

• Corollary tissues treated: Gastrocnemius, soleus See video 5.4 for the Achilles tendon PRT procedure.

Patient Self-Treatment Procedure

• Place the involved ankle on the opposite thigh.

• Move the ankle into maximal plantar flexion.

• Place the fingers over the tender area.

• Compress and rotate the calcaneus upward with the palm while using the thumb and forefinger to translate the fascia or tendon upward.

• Apply eversion, inversion, and rotation to fine-tune the position.

• Find the position of greatest tissue comfort by using the fasciculatory response method.

• Hold the position of comfort until the fascic-ulation subsides or until three to five minutes have elapsed.

Achilles tendon PRT clinician procedure.

Achilles tendon patient self-treatment procedure.

Soleus

The soleus lies deep to the gastrocnemius. The muscle is thick and broad but crosses only one joint, the ankle.

Its inferior fibers expand beyond the borders of the Achilles tendon and are therefore accessible to palpa-tion; however, deep palpation can be applied between the heads of the gastrocnemius to access the tissue in this location. The soleus primarily functions to prevent anterior translation of the tibia forward during standing, but also stabilizes the ankle during gait. The soleus can be isolated from the gastrocnemius by having the patient plantar flex the ankle while the knee is flexed.

Origin: Posterior fibular head, proximal third of the posterior and medial tibial shaft Tibial soleal line

Insertion: Calcaneus via the calcaneal tendon Action: Ankle plantar flexion, foot inversion Innervation: S1-S2 (tibial nerve)

Palpation Procedure

• The patient should be positioned prone with the knee flexed and the ankle bolstered to relax the triceps surae complex.

• Locate the Achilles tendon and slide the fingers off its borders to locate the lower portions of the soleus.

• While palpating the lower portion of the soleus, have the patient plantar flex the foot to feel its contraction.

• To palpate the deep soleus, press downward between the heads of the gastrocnemius.

• Note the location of any tender points or fas-ciculatory response of the muscle and its distal attachment site.

• Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred.

PRT Clinician Procedure

• The patient should be in a prone position.

• Position yourself next to the lower leg in either a seated or standing position.

• Move the knee through flexion and extension to find the location of greatest relaxation, which typically is between 60 and 90°.

Soleus palpation procedure.

Soleus Popliteus

Achilles tendon Plantaris

Intermediate

E6296/Speicher/Fig. 5.8/532064/JG/R1

• After finding the knee flexion position, move the ankle through plantar flexion and dorsiflexion with the far hand to find again the greatest position of comfort or fasciculation, or both.

• With the far hand or your torso, apply marked compression of the calcaneus downward, making sure to drop the elbow of the arm applying the compression downward along the line of the tibia to prevent excessive strain on your elbow.

• Apply inversion and eversion of the ankle with the far hand based on the location of the lesion.

• Apply calcaneal rotation with the far hand to fine-tune.

• Corollary tissues treated: Tibialis posterior, flexor digitorum longus, flexor hallucis longus, gastrocnemius, Achilles tendon

See video 5.5 for the soleus PRT procedure.

Soleus PRT clinician procedure.

Gastrocnemius

The gastrocnemius is a two-joint muscle that crosses the knee and ankle. Its two heads orig-inate from the femoral condyles and converge distally to form the Achilles tendon. The more robust soleus muscle underneath the gastrocne-mius also inserts into the Achilles tendon, and together they form the triceps surae complex.

In gait, the gastrocnemius serves an integral role in stabilizing the ankle joint.

Origin: Posterior femoral condyles Insertion: Calcaneus via the calcaneal

tendon; the gastrocnemius fibers insert more laterally at the calcaneus

Action: Ankle plantar flexion; assists knee flexion

Innervation: S1-S2 (tibial nerve)

Palpation Procedure

• The patient should be positioned prone with the knee flexed and ankle bolstered to relax the triceps surae complex.

• Palpate each head individually. Place a stabiliz-ing force upward with one hand on the outside of the lateral head and to the inside for the medial head while palpating upward to their tendinous aspects behind the knee.

• Determine the most dominant tender point or fasciculation (or both) and maintain light pres-sure with the pad(s) of the finger(s) throughout the treatment until reassessment has occurred.

PRT Clinician Procedure

• The patient is prone with the knee flexed to approximately 20 to 30°.

• Place the ankle into marked plantar flexion in the sulcus of your thigh or on a bolster.

• Using your far hand, evert (for the medial gastrocnemius head) or invert (for the lateral gastrocnemius head) the ankle based on the location of the tender point.

• Using your far hand, distract the talocrural joint caudally while simultaneously compressing and rotating the hindfoot downward into the talocrural joint.

• Apply calcaneal rotation to fine-tune with the far hand.

• Corollary tissues treated: Tibialis posterior, flexor digitorum longus, flexor hallucis longus, soleus, Achilles tendon, gastrocnemius tendons

Gastrocnemius (medial head)

Flexor retinaculum

Gastrocnemius (lateral head)

Achilles tendon Soleus

Superficial posterior

E6296/Speicher/Fig. 05.06/532057/JG/R1

Gastrocnemius palpation procedure.

Gastrocnemius PRT clinician procedure.

See video 5.6 for the gastrocnemius PRT procedure.