Well obviously, not EVERYTHING, but ask that question of the client at the centre of this case study and they would give you a big "YES" and probably a firm high five too.
Plantar fasciitis and Achilles tendinitis are painful inflammatory conditions that can significantly reduce quality of life. (1, 2) In this case study, we explore the use of non-invasive treatment methods, including manual lymph drainage (MLD), lymph taping, and low-level laser therapy (LLLT) in the treatment of plantar fasciitis and Achilles tendinopathy.
Case Presentation
A 49-year-old real estate agent and avid gardener, presented with pain in both feet. The pain was primarily in the heels and Achilles tendons, most intense in the morning and with the first steps after a period of inactivity, and rated by the client as 8 out of 10 most of the time. This was having an impact on their quality of life, preventing them from spending as much time in the garden as they would like, or walk their dog.
A podiatrist had diagnosed plantar fasciitis and Achilles tendinitis, performed shock wave therapy, and prescribed stretches and exercises which provided no relief or improvement.
For our sessions, we planned a course of treatment that would involve MLD, LLLT, and lymph taping with the primary aim of reducing pain.
Multi-modal treatment
Manual Lymph Drainage (MLD) was performed using the Dr Vodder Method. The gentle techniques use precise skin movements to increase the action of the lymphatic system and bring about changes in the connective tissue. (3) MLD has been shown to reduce pain (4) and inflammation. (5) Techniques and sequences learned in the Applied MLD Certificate were used including the Special techniques to locate and drain specific pockets of inflammation.
Lymph Taping uses kinesiology tape, which has the same elastic properties as the skin. Lymph tapes are applied onto stretched skin with no stretch on the tape to increase lymph flow and complement the effects of MLD. (6)
Low-Level Laser Therapy (LLLT) is the use of light in the treatment of various conditions. The laser light penetrates the skin and diffuses in the tissue, where it is absorbed by cells and converted into energy. LLLT has been shown to be useful in treating musculoskeletal pain and fibrosis in lymphoedema and is a complementary treatment to MLD. (7, 8, 9)
Treatment schedule
Six sessions of varying length were scheduled with one follow-up session. For the purpose of this case study the day of the first treatment will be referred to as day 1. The first three sessions were in close succession on days 1, 4 and 10 to take advantage of the cumulative effects of MLD.
The remaining three sessions were scheduled to be approximately one week apart on days 18, 24 and 32. The follow up session was scheduled on day 74 being six weeks after the last treatment. The client missed the appointment on day 18 so a total of five treatment sessions and one follow-up session were performed. The stretches and exercises prescribed by the Podiatrist were continued for the duration.
Results
After the first treatment the client sent a text message saying they were delighted with the results and had experienced complete resolution of pain in both feet and achilles tendons after one treatment. By the second treatment (day 4), some pain had returned after “over doing it” in the garden, but after the treatment there was again a complete resolution of pain.
At the third appointment (day 10) they reported that their feet felt very much improved and no longer had pain in the morning. They reported being careful to not stand for long periods and used the correct shoes with arch support. MLD was not performed at this session due to time constraints.
At the fourth appointment (day 24) the client observed that the absence of MLD at the last session made a big difference to the effectiveness of the treatment in reducing pain, and this was exacerbated by the long time between MLD treatments. By treatment five a week later (day 32) and after the reintroduction of MLD the client was back to having minimal pain that was only experienced after standing for too long.
Six-weeks later at the follow up appointment the client had resumed gardening and walking the dog and reported a significant improvement in all symptoms. They also commented on feeling more energized and optimistic about their recovery and had continued to perform the exercises and stretches recommended by the podiatrist to maintain their progress.
Discussion
This multi-modality case study is a good example of approaching musculoskeletal pain and limitation from a lymphatic viewpoint, using complementary adjunct therapies.
Of note was the client's observation that -
,,, treatments which including MLD were more effective.
This is due to the analgesic effect of MLD which may be attributed to several mechanisms. Gentle movements of the skin activate the light touch pain receptors which interrupt pain messages being sent to the brain, as described in the Gate Theory.(10) The shearing forces created by the two way stretch of the techniques add energy to the connective tissue changing the viscosity of the interstitial fluid from a gel state to a more sol state. This allows water molecules to move more freely (11), so when lymph pumping is also increased under MLD, the pain promoting inflammatory mediators are more easily suctioned out of the connective tissue spaces. (3, 5)
Non-invasive modalities such as MLD, lymph taping, and LLLT can be effective in reducing pain and inflammation associated with plantar fasciitis and Achilles tendinitis. These methods offer an alternative to more invasive treatments but it is important to work with a qualified healthcare professional who can provide an individual treatment plan to achieve the best outcomes.
What I learned
This was an interesting case study with good results achieved. There were some challenges around appointment scheduling due to availability. The variations in appointment duration and the use of multiple modalities make it difficult to replicate, but are a true reflection of a real life case.
The process of writing this report highlighted the need for me to implement a system to routinely collect client feedback regarding scores for pain and quality of life. A likert scale or similar can be used to measure treatment outcomes and be invaluable when writing retrospective reports. Photos and tape measures are also gold 🤩
Another takeaway, and some self-reflection … we can have a tendency to be quite enthusiastic in our approach. I would recommend against throwing everything you’ve got in your toolkit at something all at once. Yes, we get great results but how do we differentiate and identify what is, or isn’t working?
Maybe the title should have been "Everything, everywhere, all at once" … shame someone else thought of it first.
Disclaimer: Client consent was given for the use of content and photos.
References:
1. Buchbinder R. Plantar fasciitis. New England Journal of Medicine. 2004 May 20;350(21):2159-66.
2. Mazzone MF, McCue T. Common conditions of the achilles tendon. Am Fam Physician. 2002 May 1;65(9):1805-10. PMID: 12018803.
3. Textbook of Dr Vodder’s Manual Lymph Drainage A Practical Guide, Wittlinger 2011. Georg Thieme Verlag
4. Kim SJ. Effects of manual lymph drainage on the activity of sympathetic nervous system, anxiety, pain, and pressure pain threshold in subjects with psychological stress. The Journal of Korean Physical Therapy. 2014;26(6):391-7.
5. Williams A. Manual lymphatic drainage: exploring the history and evidence base. Br J Community Nurs. 2010 Apr;15(4):S18-24. doi: 10.12968/bjcn.2010.15.Sup5.78111. PMID: 20559172.
6. Malicka, I., Rosseger, A., Hanuszkiewicz, J. and Woźniewski, M., 2014. Kinesiology Taping reduces lymphedema of the upper extremity in women after breast cancer treatment: a pilot study. Menopause Review/Przegląd Menopauzalny, 13(4), pp.221-226.
7. Karu TI. Cellular and molecular mechanisms of photobiomodulation (low-power laser therapy). IEEE Journal of Selected Topics in Quantum Electronics. 2013 Sep 18;20(2):143-8.
8. Cotler HB, Chow RT, Hamblin MR, Carroll J. The use of low level laser therapy (LLLT) for musculoskeletal pain. MOJ orthopedics & rheumatology. 2015;2(5).
9. Tumilty SJ. Low level laser therapy for the treatment of tendinopathy with emphasis on the achilles tendon (Doctoral dissertation, University of Otago).
10. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965; ISH: 971±9
11. Cowman MK, Schmidt TA, Raghavan P, Stecco A. Viscoelastic Properties of Hyaluronan in Physiological Conditions. F1000Res. 2015 Aug 25;4:622. doi: 10.12688/f1000research.6885.1. PMID: 26594344; PMCID: PMC4648226
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