Treatment of chronic Achilles tendon pain by

Kinesio taping in an amateur badminton

player
Physical Therapy in Sport 13 (2012) 115-119
Jung-hoon Lee , Won-gyu Yoo

Journal Reading IV
Presentan : dr Agung Setiawan
Moderator : dr Tanti Ajoe K, SpKFR,M.Si Med
 ABSTRACT
• Objective: To evaluate the effects of Kinesio taping
on a patient with chronic Achilles tendon pain.
• Design: Case report.
• Case description: A 22-year-old male amateur
badminton player slipped on the ground as he
landed after jumping while playing badminton,
resulting in chronic Achilles tendon pain of the
dominant (right) leg. We performed Achilles tendon
taping (ATT) over 5 weeks.

2
 ABSTRACT
• Results: The patient’s ultrasonography showed that the
tendon thickness was moderately reduced from 0.42 cm to
0.37 cm and that the angles of active dorsiflexion and
active plantar flexion without pain increased from 150 to
200 and from 200 to 450, respectively. The Victorian
Institute of Sport Assessment- Achilles (VISA-A)
questionnaire score increased from 64 to 95, and the load-
induced pain assessment score decreased from 6 to 0.
The pain threshold increased from 0.8 kg to 10 kg. The
tenderness at 3 kg, assessed on a numeric rating scale,
decreased from 7 to 0, and the patient was able to play
badminton and soccer without pain.

3
 ABSTRACT

• Conclusions: We verified the effect with an

increase in the active ankle joint range of motion
and the VISA-A questionnaire score, which was
achieved by a decrease in tenderness and pain
from repeated ATT application.

4
 INTRODUCTION
• Achilles tendon injuries occur frequently among
athletes participating in running, orienteering,
badminton, tennis, soccer, and volleyball
• Badminton in particular is a sport that involves
repeated, rapid forward lunges; the dominant leg
bears a greater load, and tendons are heavily strained
• When acute tendonitis occurs, the inflammation is
most often characterized by swelling, local pain, and
occasionally crepitus.
• At this stage, symptomatic treatments such as rest,
non-steroidal antiinflammatory drugs, heel lifts, and
local physical therapy are used to control the
inflammation and heal the injured tendon 5
 INTRODUCTION
• Tendinosis are chronic, but generally not
inflammatory, although the area can be painful to
touch, and this condition is characterized by tendon
degeneration
• Based on the etiology, Achilles tendinosis can be
caused by a combination of failure of the normal
healing mechanisms and repeated trauma
• At this stage, pathological processes including
localized painful thickening of the tendon increase.
• Ultrasonography has been used to quantify Achilles
tendon degeneration

6
 INTRODUCTION
• The use of Kinesio Taping (KT) for the treatment of
joint sprains and instability, soft tissue inflammation,
and muscle pain and weakness
• However, the effect of KT on various sports injuries
has not been sufficiently studied. This case report is
the first to describe the results of KT on a patient
with chronic Achilles tendon pain.

7
 CASE DESCRIPTION
• A 22-year-old male amateur badminton player
slipped on the ground as he landed after jumping
while playing badminton 6months previously,
resulting in pain in the Achilles tendon of the
dominant (right) leg.
• The pain was slightly relieved after receiving
therapeutic ultrasound, undergoing transcutaneous
electrical nerve stimulation (TENS), and stopping
sports activity that might provoke pain.

8
 CASE DESCRIPTION
• However, he was not able to undergo continuous
treatment. Within a month, he developed severe
pain during active plantar flexion and palpation of
the pre-insertional area of the Achilles tendon after
returning to play badminton.
• The patient was not able to sit on his knees (e.g.,
ankle plantar flexion position), play badminton, or
play soccer because he was not able to run or kick
the ball.

9
 INITIAL ASSESSMENT
– The initial ultrasonography showed that the pre-insertional area
of the right Achilles tendon, where the pain was found, was
mildly thicker (0.42 cm) (Fig. 1) than that of the left Achilles
tendon (0.38 cm).
– Active dorsiflexion (ADF) and active plantar flexion (APF),
measured with a goniometer, were 15° (population normal angle,
20°) and 20° (population normal angle, 45°), respectively, due to
pain.
– The VISA-A questionnaire is a reliable and valid instrument for
the evaluation of pain intensity and levels of function in patients
with Achilles tendon disorders
– Scores on this eight-item questionnaire range from 0 to 100. A
score of 100 indicates no pain and complete function . The
VISA-A questionnaire score was 64 (population normal range
>95)

10
 INITIAL ASSESSMENT
– the load-induced pain, assessed on a numeric rating scale from
0 to 10 (e.g., 0 representing no pain and 10 representing the
worst imaginable pain), was 6
– The pressure- pain threshold was assessed with an algometer
(Pain Test-Model FPK; Wagner Instruments, Greenwich, CT).
The algometer was pressed against the tenderest area of the
right Achilles tendon, and the pressure was increased by 0.1
kg/s until the patient experienced pain; the PPT was 0.8 kg.
– defined tenderness using a numeric rating scale following the
application of 3 kg of pressure to the tenderest area of the
Achilles tendon. The tenderness determined using an algometer
at 3 kg was 7 on a numeric rating scale of 0-10.

11
INTERVENTION: ACHILLES
TENDON TAPING

12
RESULTS

13
RESULTS

14
 RESULTS
• While running and jumping, the Achilles tendon is subjected to loads
as high as 6-12 times the body weight. Such high repetitive loading
is considered to be one of the main pathological stimuli to the
Achilles tendon (Paavola, Kannus, Järvinen, Khan, Józsa, &
Järvinen, 2002).
• Badminton is a sport that requires jumps, lunges, quick hand
motions, and changes in direction in a wide variety of postural
positions (Shariff, George, & Ramlan, 2009). When landing after a
jump while playing badminton, the body is upright while the ankle is
maintained in a plantar-flexed position due to the activity of the
gastrocnemius and soleus muscles (Schepsis et al., 2002).
• In the present case, the original injury was caused by the ankle
being forced upwards while in a plantar-flexed position when landing
after a jump during badminton, leading to a compression injury of
the Achilles tendon.
15
 RESULTS
• Furthermore, continuous treatment was not provided in the acute
phase, and the patient continued to play badminton prior to
complete recovery.
• Thus, the severe pain may have occurred gradually as repetitive
microtrauma was imposed on the Achilles tendon. Based on the
etiology, the Achilles tendinosis was caused by a combination of
failure of the normal healing mechanisms and repeated trauma
• In this case, a limited range of motion of approximately 5° in ADF
and 25° in APF werefound because of the pain. The peritendinous
tissue appears thickened while crepitation and swelling diminish
inflammation is absent. At this stage, the patient is generally unable
to perform sports

16
 RESULTS
• previous studies show that the rationale for KT applied to the
Achilles tendon and gastrocnemius and soleus muscles is to protect
and support the joint during functional ankle.
• In addition, the elasticity of Kinesio tape may improve blood and
lymph circulation and decrease pain
• Different from conventional tapes, Kinesio tape has an elasticity of
130-140% which allows ankle movement in both dorsiflexion and
plantar flexion with ATT
• In this case, the skin of the affected area was stretched before the
application of KT through ankle dorsi- flexion. After Kinesio tape is
stretched by 130-140%, the taped skin forms convolutions when the
skin and muscles return to their neutral positions .The flow of
lymphatic fluid is limited when the space beneath the skin is
compressed
17
 RESULTS
• Such compression provides pressure to the pain receptors beneath
the skin and gives a “discomfort signal,” which is pain (Kase, 2003).
• The stretched Kinesio tape application may increase the space
beneath the skin as the skin is lifted by convolution, and the flow of
blood and lymphatic fluid may be improved (Kase, 2003).
• In a previous study, elastic adhesive tape application during
passive exercise resulted in a significant increase in the lymph flow
rate compared with the absence of exercise with tape (Shim, Lee, &
Lee, 2003).
• Increased tension may facilitate a pain inhibitory mechanism (e.g.,
gate control theory) by providing an afferent stimulus to large-
diameter nerve fibers to mitigate nociception
• As the patient’s pain level was reduced, the fear of pain during ankle
movement might have been reduced by proper sensory feedback,
thus improving ankle range of motion
18
 RESULTS
• Stimulation of cutaneous mechanoreceptors by KT activates nerve
impulses, leading to local depolarization, which triggers nerve
impulses to travel along afferent fibers to the central nervous system
(Kase et al., 2003).
• In recent studies, KT increased the EMG activity of the scapular
muscles (Lin et al., 2011), lower trapezius muscle (Hsu, Chen, Lin,
Wang, & Shih, 2009), and vastus medialis muscle (Slupik, Dwornik,
Bialoszewski, & Zych, 2007). Additionally, KT application on the
anterior surface of the thigh leads to increases in the isokinetic
eccentric peak torque of the vastus medialis, vastus lateralis, and
rectus Thus, KT application may improve the muscle activity of the
calf muscles, reducing Achilles tendon loading.
• Also, the third I-type strip application technique to elevate the
calcaneus in the ankle mortise might have acted as the mechanical
correction that improved the range of motion during active plantar
flexion 19
 CONCLUSION
• We applied ATT with Kinesio tape to our patient, who
was not able to perform sports activities because of the
limited range of motion in the ankle joint due to
tenderness and pain in the Achilles tendon. We verified
the effect with an increase in the active ankle joint range
of motion and the VISA-A questionnaire score, which
was achieved by a decrease in tenderness and pain

20
 ISTILAH DALAM GAIT PATTERN
1. Gait cycle/ stride length
•Satu periode antara saat tumit satu kaki
mencapai lantai (heel strike/ HS) hingga HS
berikutnya dari kaki yang sama

22
 ISTILAH DALAM GAIT PATTERN
2. Stance phase
Satu rangkaian gerakan yang dimulai saat HS hingga
ibu jari dari kaki yang sama meninggalkan lantai (toe
off)

Terdiri dari:
1. Heel strike
2. Flat foot
3. Mid stance
4. Push off

23
Stance phase terdiri dari :
–Heel strike : dimulai saat tumit dari kaki atau
sepatu mengenai lantai atau tanah.
–Flat foot/FFl : segera setelahHS dimana
seluruh
telapak kaki menapak lantai.
–Mid stance/Mid st : segera setelah FFl dimana
posisi kaki yang mengenai lantai tersebut menjadi
tegak lurus searah dengan badan, dan seluruh
berat badan (BB) terpusat pada kaki.
–Push off : satu fase yang dimulai saat tumit lepas
dari lantai (heel off) dan berakhir bila ibu jari
meninggalkan lantai (toe off). Heel off terjadi
segera setelah Mid st.
24
 ISTILAH DALAM GAIT PATTERN
3. Swing phase
Rangkaian gerakan mulai toe off hingga heel strike
dari kaki yang sama

Terdiri dari:
1. Acceleration
2. Mid swing
3. Deceleration

25
 Swing phase terdiri dari :

– Acceleration :
dimulai saat ibu jari lepas meninggalkan lantai (toe off).
Gerakan selanjutnya tungkai harus dipercepat untuk
mencapai lantai (HS) dari kaki berikutnya.
– Mid swing :
terjadi saat kaki mengayun cepat dan berada pada posisi
persis dalam satu garis dengan badan. Kaki tersebut pada
posisi cukup pendek dengan fleksi pada paha dan lutut
agar tumit tidak menyentuh lantai.
– Deceleration :
Gerakan lambat dari kaki yang terkontrol sebelum tumit
mengenai lantai (HS) berikutnya. 197
27
 ISTILAH DALAM GAIT
PATTERN
4. Double support
– Periode dimana kedua kaki kontak dengan tanah, dimana
satu kaki pada posisi HS dan telapak kaki lainnya pada
posisi toe off
– Double support dapat digunakan untuk membedakan
antara lari dan jalan cepat.

Distribusi waktu selama satu periode gait :

GAIT CYCLE TIME DISTRIBUTION
Stance phase 60%
- Double support 25%
Swing phase 40%
28
 ISTILAH DALAM GAIT PATTERN
5. Cadence
• Merupakan jumlah langkah selama 1 menit (step/menit)
– Normal 110
– Lambat 70
– Cepat 130
– Lari > 130
• Rata-rata normal 90, kecepatan 70-75 m/menit, perlu
energi 2,5 cal/menit untuk jarak 2,5 mil
• Energi yang dibutuhkan untuk jalan kaki dengan langkah
lambat lebih tinggi daripada jalan cepat -> berkaitan
dengan energi yang dibutuhkan untuk stabilisasi tubuh
yang berasal dari kontraksi otot lebih banyak 200
 FAKTOR PENENTU GAIT
(DETERMINANT OF GAIT)
•CoG harus tidak berubah  1 siklus gait
tidak
memerlukan energi yang banyak
•CoG akan tetap pada tempatnya  pada
bidang horizontal bila sendi paha, lutut
dan pergelangan kaki bergerak
sedemikian rupa  menghasilkan pola
jalan yang menarik dengan kebutuhan
tenaga yang sedikit
•Syarat terjadinya gerak seperti diatas
disebut sebagai determinants of gait 
menentukan pergerakan CoG pada garis 30

horisontal
 TUJUAN DETERMINANT
1. Mengurangi perubahan posisi CoG 
mengurangi pengeluaran energi yang dibutuhkan
untuk menaikkan dan menurunkan CoG
2. Mempertahankan panjang relatif dari kaki 
langkah kaki dengan sendirinya tetap besar 
jalan lebih cepat, tanpa meningkatkan cadence
dan energi yang dibutuhkan lebih sedikit

31
 PEMBAGIAN DETERMINANT
1. Pelvic rotation
2. Pelvic tilt
3. Fleksi lutut pada waktu
stance phase
4. Foot and ankle
mechanism
5. Lateral displacement of
pelvis
6. Axial rotation
32
 ANALISIS BIDANG SAGITAL
• Heel strike – mid stance
Kinematik Ankle Knee Hip
Heel strike 90° netral antara plantar Lutut lurus 180° Fleksi 25° lalu
(HS) dan dorsofleksi (ekstensi), mulai FFl bergerak ke arah
maka fleksi dimulai ekstensi sesuai gerak
badan ke depan

Bergerak ke arah plantar Akhir FFl, fleksi 20° Fleksi 20°

fleksi sampai 15°

Mid stance Tibia bergerak ke depan Fleksi lutut berkurang Sendi paha netral
telapak kaki seolah-olah menjadi 15° (180°)
dorsofleksi 2-3°

33
 ANALISIS BIDANG SAGITAL
• Mid stance – toe off
Kinematik Ankle Knee Hip

Mid stance 3-5° dorsofleksi Fleksi 15° bergerak ke Sendi paha netral
arah ekstensi

Heel off 15° dorsofleksi Ke ekstensi 180° Hiperekstensi

Toe off Bergerak ke arah Fleksi 40° Hiperekstensi

plantar fleksi 35° maksimal 20°
hingga telapak kaki 20°
plantar fleksi

34
 ANALISIS BIDANG SAGITAL
• Swing phase
Kinematik Ankle Knee Hip

M. Tibialis anterior, m. Perubahan fleksi sampai 65° Mula-mula

Ext. Digitorum longus, (acceleration) 180°
m. Ext. Hallucis longus
aktif sampai posisi 90°
Waktu akselerasi Fleksi sampai
mm.quadriceps dan 25° pada saat
iliopsoas aktif untuk midswing
mencegah naiknya tumit ke
belakang dan membantu
akselerasi ke depan
Selama fase ini tungkai Waktu deselerasi Selama fase
terputar ke dalam m.hamstring aktif untuk deselerasi,
(endorotasi) mencegah gerak berlebih tetap fleksi 25°
dari lutut ke depan 206
 GAIT ANALYSIS

SAGITTAL
PLANE

FRONTAL
PLANE

207
 OTOT-OTOT DAERAH
LUTUT
QUADRICEPS FEMORIS
• Kelompok ekstensor lutut
• Melekat pada patella dan tibia pada 3 permukaan
• Superficial : rectus femoris
• Medial : vastus lateralis & vastus medial
• Dalam : vastus intermedius
• Inervasi : N. femoralis
HAMSTRING
• Kelompok fleksor lutut
• Lateral : m. Biceps femoris -> untuk flexi dan eksternal rotasi
tibia
• Medial : m. Semimembranosus & M. Semitendinosus ->
untuk flexi sendi lutut & internal rotasi tungkai bawah 164
 165
M. QUADRICEPS FEMORIS
 OTOT-OTOT DAERAH
LUTUT
GASTROCNEMIUS

• Kelompok plantar flexor

• Melekat pada epicondylus medialis & lateralis menuju
calcaneus membentuk tendon achiles

POPLITEUS
• Menarik kantong sinovial saat fleksi sehingga tidak terjepit

166
M. HAMSTRING, M.GASTROCNEMIUS, M.POPLITEU1S67
 GERAKAN SENDI
LUTUT

Sagital plane Axis Horisontal plane Axis

transversal Flexi- longitudinal
extensi External-internal rotation

168
 GERAKAN SENDI LUTUT

• Gerakan flexi - extensi dari sendi lutut akan disertai

dengan gerakan meluncur dari tibia terhadap femur,
yang terjadi pada saat lutut extensi dan
• Pada posisi lutut flexi lebih 20°, ligamen-ligamen
disekitar sendi lutut akan relax dan membiarkan
terjadinya gerakan meluncur dan axial rotasi.
• Rotasi yang paling besar terjadi pada saat gerakan
mendekati full flexi dan sewaktu gerakan 30-40°
mendekati full extensi.
43
KINESIOLOGI
PERGELANGAN KAKI
DAN KAKI

44
SUSUNAN TULANG
•Sendi pergelangan kaki
dibentuk oleh artikulasi antara
ujung distal fibula dan tibia
dengan talus.
•Untuk stabilisasi kaki
diperlukan
ligamentum yang kuat pada sisi
lateralis
45
 SUSUNAN TULANG

• Jumlah tulang-tulang kaki ada 26 buah, terdiri

dari 7 os tarsalia, 5 os metatarsalia dan 14 os
phalangs,
• Dibagi menjadi 3 segmen
– Posterior dibentuk oleh calcaneus dan talus.
– Medial dibentuk oleh cunciforme cuboideum
dan naviculare
– Anterior dibentuk oleh 5 os tarsalia, 14 os
phalanges
46
47
 PERSENDIAN ANKLE & FOOT

1. ANKLE MORTISE
• Dibentuk : tibia, fibula, dan talus
diantara kedua maleolus
• Gerakan : dorso-plantar fleksi

2. SENDI SUBTALAR/ TALOCALCANEAL

JOINT

3. SENDI TARSAL TRANSVERSUM/

Surgeon’s tarsal joint / Midtalar joint/
Chopart’s joint  Talo-Navicular &
Calcaneo-Cuboid

4. SENDI METATARSOPHALANGEAL

5. SENDI INTERPHALANGEAL
 LIGAMENT OF ANKLE & FOOT

LIGAMEN DARI ANKLE LIGAMEN COLLATERAL LIGAMEN COLLATERAL

MORTISE LATERAL MEDIAL/ LIG. DELTOID

LIG. LIG.
LIG. INTRAOSSEUS TIBIONAVICULARE
TALOFIBULARE
ANTERIOR LIG. TALOTIBIALE
LIG. TIBIOFIBULAR ANTERIOR
LIG. CALCANEO
ANTERIOR FIBULARE LIG. CALCALO
TIBIAL
LIG.
LIG. TIBIOFIBULAR TALOFIBULARE LIG. TALOTIBIALE
POSTERIOR POSTERIOR POSTERIOR
LIGAMEN ANKLE MORTIS
 LIGAMEN
COLLATERAL
 OTOT KAKI

EKSTRINSIK INTRINSIK

POSTERIOR ANTERIOR LATERAL MEDIAL

 SUPERFICIAL POSTERIOR GROUP

Gastrocnemius Soleus
Terdiri dari 2
caput

Origo Condylus lat & Caput fibula

Med Femur posterior &
garis soleus
tibia

Insersio Menuju calcaneus Menuju

menjadi tendon calcaneus
achiles menjadi
tendon
achiles

Gerakan Plantar fleksi& Plantar fleksi

supination kaki

Inervasi N. Tibialis posterior

179
 ANTERIOR GROUP
1. M. Tibialis Anterior

2. M. Extensor
digitorum longus N.Peroneal
profundus
3. M. Extensor hallucis
longus

4. M. Peroneus tertius
 MEDIAL GROUP

1. Tibialis Posterior

2. Flexor digitorum
longus
N. Tibialis
Posterior
3. Flexor hallucis
longus
 LATERAL GROUP

Muscle Action Nerve

1. Peroneous longus
(Higher & more superficial) Plantar fleksi
N. Peroneus cabang
superficial
2. Peroneous brevis (Lower & Eversi
deeper)

182