GROUP 1 PRESENTATION ON

ANKYLOSING SPONDYLITIS
AND
ACHILLES TENDON RUPTURE
 ANKYLOSING SPONDYLITIS (AS)
Definition:

Ankylosing spondylitis (AS) also known as Axial Spondyloarthritis, is a chronic, progressive,

inflammatory rheumatic disease that primarily affects the axial skeleton, especially the
sacroiliac joints and spine. It is characterized by pain, stiffness, and eventual fusion (ankylosis)
of the vertebrae (bones of the spine). It is classified under seronegative spondyloarthropathies
(a group of inflammatory rheumatic diseases that primarily affect the spine and sacroiliac joints,
which often show negative rheumatoid factor (RF) in blood tests).

Causes (Etiology):

The exact cause of AS is unknown, but several factors contribute. Some of them are;

1. Genetic Factors – Ankylosing Spondylitis is strongly associated with the HLA-B27 gene,
however many people with the gene live their lives without developing the condition.

2. Autoimmune Response – The condition might develop as a result of the immune system
mistakenly attacking the joints and ligaments.

3. Environmental Factors – Exposure to bacteria Klebsiella Pneumoniae may trigger AS in

genetically predisposed individuals

4. Family History – There is increased risk of developing AS if first-degree relatives are

affected.

5. Gender – It occurs more commonly in males than females.

6. Age – The illness typically begins between late adolescence and early adulthood (15–35
years).

7. Infections – Gastrointestinal or genitourinary infections may act as triggers.

8. Hormonal Factors – Hormonal imbalances may influence onset.

9. Smoking – Smoking is associated with increased disease severity.

10. Obesity –May contribute to increased spinal stress and inflammation.

 Types of Ankylosing Spondylitis:

1. Axial Ankylosing Spondylitis:

This type primarily affects the spine and sacroiliac joints. It causes back pain, stiffness, and
limited spinal mobility. It is the most common type.

2. Peripheral Ankylosing Spondylitis:

This type affects the limb joints (e.g., shoulders, hips, knees). It may present with enthesitis
(inflammation at tendon/ligament insertion).

3. Juvenile Ankylosing Spondylitis (JAS):

This typically manifests before age 16. It is more likely to begin with peripheral joint symptoms
before axial involvement.

4. Non-radiographic Axial Spondyloarthritis (nr-axSpA):

This is an early form of AS without visible damage on X-rays. It is detected using MRI and with
the presence of symptoms and HLA-B27.

Signs and Symptoms

a. Chronic Lower Back Pain: Especially in the morning or after inactivity, improves with
exercise.

b. Morning Stiffness that lasts more than 30 minutes.

c. Limited Spinal Mobility: Reduced flexibility of the spine.

d. Pain in Buttocks and Hips: Due to sacroiliac joint inflammation.

e. Fatigue: Due to chronic inflammation and poor sleep quality.

f. Enthesitis: Inflammation at ligament or tendon insertion sites (e.g., Achilles tendon).

g. Kyphosis: Forward curvature of the spine (hunched posture).

h. Uveitis: Inflammation of the eye, causing pain, redness, and blurred vision.

i. Loss of Appetite and Weight Loss: This is seen in chronic cases.

j. Breathing Difficulty: Due to restricted chest wall movement

Diagnostic Tests:

1. Physical Examination:

a. Spinal flexibility tests (Schober’s test): This is used to evaluate lumbar flexion (forward
bending motion of the lower back)

b. Tenderness over sacroiliac joints.

1. Laboratory Tests:

a. HLA-B27 gene Testing: The gene appears positive in 90% of AS patients.

b. Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) levels: These are
elevated due to inflammation.

c. Rheumatoid Factor (RF) and Antinuclear Antibodies (ANA): These usually appear
negative in AS and it helps differentiate AS from rheumatoid arthritis.

2. Imaging Tests:

a. X-rays: Show sacroiliitis and spinal changes (there will be presence of bamboo spine in
advanced stages).

b. MRI: This is used in early detection of inflammation in the sacroiliac joint and spine.

c. CT Scan: This is used for detailed bone structure analysis.

Prevention

AS cannot be completely prevented, but progression can be delayed with the following
interventions;

a. Regular exercise and posture training.

b. Avoiding smoking and reducing alcohol.

c. Early detection and treatment.

d. Ergonomic adjustments to reduce spinal strain.

Complications

a. Spinal fusion (ankylosis)

b. Osteoporosis

c. Restricted chest expansion (leading to breathing difficulty)

d. Cardiac issues (e.g., aortitis)

e. Eye inflammation (uveitis)

f. Neurological complications (due to spinal fractures)

g. Depression and anxiety

h. Reduced mobility and quality of life

Treatment

1. Pharmacological:

a. NSAIDs (e.g., ibuprofen, naproxen): These are first-line treatments for pain and
inflammation.

b. Tumor Necrosis Factor (TNF)-alpha inhibitors (e.g., etanercept, infliximab): This is used
in the management of moderate to severe AS.

c. IL-17 (Interleukin 17) inhibitors (e.g., secukinumab): Alternative biological therapy. It

blocks IL-17 which plays a major role in immune system inflammatory response.

d. Disease Modifying Antirheumatic Drugs (DMARDs) (e.g., sulfasalazine): These are used
in the management of peripheral arthritis.

e. Corticosteroids: These should be used short-term, during flares.

2. Non-Pharmacological:

a. Physical therapy: This improves mobility and posture.

b. Posture training: This helps prevent deformities.

c. Breathing exercises: Improves lung capacity.

d. Occupational therapy: Supports daily functioning.

e. Psychological support: For managing chronic disease impact.

 3. Surgical:

a. Joint replacement surgery (hip/knee) is done in severe cases.

b. Spinal surgery: This is rarely done and only for deformities or fractures.

Nursing Management Using the Nursing Process

a. Assessment

 Assess pain level, range of motion, functional ability, fatigue, posture, and emotional
status.

 Monitor vital signs

 Monitor for signs of inflammation.

b. Diagnoses

 Chronic pain related to disease process

 Impaired physical mobility

 Fatigue

 Risk for impaired gas exchange

c. Planning

 Pain reduction

 Improved mobility

 Adherence to treatment

d. Implementation

 Administer prescribed medications

 Assist in physical therapy

 Teach posture exercises

 Provide emotional support

 Educate on self-care.

e. Evaluation
  Monitor for reduced pain and improved function

 Monitor for treatment adherenceand patient satisfaction.

 Adjust care plan as needed.

Nursing Care Plan

Nursing Nursing Nursing Scientific Evaluation

Diagnosis Outcome Intervention Rationale

1.Chronic pain Patient will a. Encourage a. Heat therapy Patient

related to have heat and will aid in verbalized
inflammation reduction of cold soothing stiff reduction in
pain level therapy joints and pain levels,
within 1 week relaxing the 2/10
b. Administer
of nursing muscles, and
prescribed
intervention cold therapy
analgesics
will reduce
inflammation
and swelling.

b. Analgesics
will help
relieve
inflammation,
and reduce
pain
perception in
the brain.

2. Impaired Patient will a. Encourage These will help Patient

Physical have active ROM maintain joint demonstrates
Mobility improved exercises. function and prevent improved
range of deformity. mobility and
b. Assist
motion and posture.
patient
posture
with
within 1 week
ambulation.
of
intervention.
 3. Fatigue Patient will a. Encourage a. Conserves Patient
related to have activity-rest energy and reports
chronic illness improved balance improves increased
energy levels well-being energy within
b. Assess
within 1 week 5 days.
nutrition b. Focusing on
of
and sleep nutrient-rich,
intervention.
energy
boosting
foods like
lean proteins,
nuts and
green leafy
vegetables,
will help
reduce
fatigue.

ACHILLES TENDON RUPTURE

Definition:
An Achilles tendon rupture is a complete or partial tear of the Achilles tendon, which is the
fibrous cord that connects the calf muscles (gastrocnemius and soleus), to the heel bone
(calcaneus). This injury typically results in a sudden loss of strength and function in the affected
leg, making walking or pushing off the foot difficult. It is common for patients to describe that
they heard a “popping” sound at the back of the leg, or the feeling of having been kicked in the
back of the ankle.

Causes:

Achilles tendon rupture often results from sudden stress or trauma to the tendon, especially
during high-impact activities. Some of the main causes are:

a. Sudden Increase in Physical Activity

Rapid or intense activities, such as sprinting or jumping, especially in people who are not well-
conditioned, can strain the tendon beyond its capacity.

It is common in a group of people called "weekend warriors", they are individuals who are
mostly inactive during the week and engage in intense physical activities on weekends.

b. Sports-Related Injuries

Sports like basketball, soccer, tennis, and track, which require explosive movements, jumping
and rapid changes in direction, pose a high risk. Tendon tear often occurs during take-off or
landing movements.

c. Direct Trauma

A direct blow to the Achilles tendon or forceful dorsiflexion of the ankle (such as falling or
tripping) can cause rupture.

d. Degenerative Changes (Tendinopathy)

Long-term wear and tear or micro-tears can weaken the tendon over time, especially in aging
individuals. Certain conditions like tendinitis (inflammation of the tendon) can precede rupture.

e. Medication and Medical Conditions

Long-term use of corticosteroids or fluoroquinolone antibiotics (eg ciprofloxacin) is associated

with tendon degeneration and increased risk of rupture.
Conditions like diabetes, obesity, rheumatoid arthritis, and hypercholesterolemia may impair
tendon health.

Types of Achilles Tendon Rupture

a. Complete Rupture

In this type, the tendon is completely torn, with a clear gap between the torn ends. This causes
a sudden sharp pain in the back of the ankle and heel. It can significantly cause inability to push
off the foot, difficulty walking, especially on toes, and a sudden drop in function.

b. Partial Rupture

Here, the tendon is only partially torn. Some of the fibers within the tendon are torn, but not
all. Some function is preserved, but there may be pain, weakness, and swelling. The tear may be
mild or more significant, depending on the individuals’ level of activity.

c. Acute Rupture:

In this case, the rupture is recent, usually sudden and traumatic. It occurs immediately after
injury.

d. Chronic Rupture:

This occurs about 4-6 weeks after injury. It is often misdiagnosed or neglected. It is typically
characterized by a weakened or elongated tendon due to formation of scar tissue. It results in
decreased strength in the calf muscle, and atrophy.

Signs and Symptoms:

a. Sudden, sharp pain in the back of the ankle or calf (described as feeling like being kicked
or shot).
b. Popping or snapping sound at the time of injury.
c. Swelling and bruising around the heel or lower calf.
d. Difficulty walking or rising on toes.
e. Weakness in the foot or inability to push off.
f. Visible gap or depression in the tendon above the heel.

Diagnostic Tests:
1. Physical Examination
 Thompson Test: The patient lies prone while the examiner squeezes the calf. Lack of
foot movement (plantar flexion) suggests rupture.
 Palpation: The heel is palpated gently to detect gap in tendon.
 2. Imaging
 Ultrasound: This is a quick and effective tool for visualizing tendon rupture and gap.
 MRI (Magnetic Resonance Imaging): This will provide detailed images of tendon
integrity. It is especially useful for planning surgery or diagnosing partial tears.
 X-ray: This is not useful for soft tissue injuries but may be used to rule out associated
bone injuries.

Complications:

1. Re-rupture of the tendon could occur (especially if the initial tear is poorly managed or
prematurely returned to activity).
2. Long-term weakness or reduced ankle mobility.
3. Tendon elongation during healing, leading to decreased strength.
4. Post-surgical complications like infection, scarring, or adhesions.
5. Deep vein thrombosis (DVT) due to immobility.

Prevention:

1. Proper warm-up before exercise and stretching of calf muscles.

2. Gradual increase in activity level.
3. Wearing appropriate footwear for sports or exercise.
4. Avoid sudden intense exercise, especially if untrained.
5. Treat and manage Achilles tendinitis or pain early to avoid degeneration.
6. Avoid unnecessary corticosteroid injections near the tendon.

Treatment:

Treatment can be surgical or non-surgical, depending on the severity of the injury.

a. Non-Surgical

The non-surgical approach is often used for partial ruptures or in patients who are elderly or
those who have low physical demands. It involves immobilization of the affected limb in a cast
or boot with the foot in plantar flexion for 6–8 weeks. It is followed by gradual weight-bearing
and physical therapy.

b. Surgical

This approach is recommended for complete ruptures or active individuals. It involves suturing
the torn ends of the tendon, followed by immobilization and extensive rehabilitation. It can
take about 6–12 months for one to make a full recovery.
Nursing Management Using Nursing Process

a. Assessment
 History taking: We would need to know the mechanism of injury (how the injury
happened), onset of pain, and if there’s a history of previous Achilles problems.
 Physical assessment: We assess the patient for pain, swelling, inability to move the
ankle, any gait changes, ability to stand on their toes.
 Monitor neurovascular status: Pulse, temperature, color, capillary refill, sensation.
b. Nursing Diagnoses
 Acute Pain related to tissue injury.
 Impaired physical mobility related to tendon rupture.
 Risk for impaired skin integrity related to immobilization device.
 Deficient Knowledge related to post-operative care and rehabilitation.
c. Plan
 Alleviate pain.
 Prevent complications.
 Promote optimal recovery and function.
 Educate the patient on rehabilitation and self-care.
d. Implementation
 Administer prescribed analgesics and anti-inflammatory medications.
 Apply ice, elevate affected limb to reduce swelling.
 Assist with mobility (crutches, walker).
 Teach patient about use of brace or cast.
 Encourage compliance with rehabilitation protocol.
 Prevent complications: Perform skin care, encourage leg exercises to prevent DVT.
e. Evaluation
 Patient reports pain relief.
 Absence of complications like infection or DVT.
 Patient demonstrates correct use of assistive devices.
 Improved mobility and return to pre-injury activities.

Nursing Care Plan:

Nursing Nursing Nursing Scientific Evaluation

Diagnosis Outcome Intervention Rationale

1.Acute pain Patient will a. Elevate a. Elevating the Patients

related to verbalize a affected leg will help verbalized
tissue injury reduction in limb. to alleviate pain
evidenced by pain level b. Apply cold pain and reduction, to a
patients’ within 60 compress swelling. 3 on the pain
verbalization minutes of for about b. Cold scale, 45
and facial nursing 15-20 compress minutes after
grimace. intervention. minutes at can help to nursing
intervals. reduce intervention.
c. Administer inflammation
prescribed and
analgesics. discomfort
and swelling
(by
constricting
the blood
vessels in the
area)
c. Analgesics
will help
reduce the
perception of
pain by
working on
the pain
receptors of
the brain.

2.Impaired Patient will a. Encourage a. Physical Patient

physical regain full participation therapy will demonstrates
mobility range of in physical help restore improved
related to motion and therapy. muscle range of
Achilles strength in b. Assess range strength and motion and is
tendon the affected of motion tendon able to
rupture as leg within 6 and strength flexibility. ambulate
evidenced by months. regularly. b. This helps independently
inability to c. Educate monitor with minimal
walk or rise on patient progress and discomfort.
toes. about non- adjust
weight- rehabilitation
bearing plan as
 methods. needed.
c. This will
prevent
further injury
and support
healing.

3.Risk for Patient skin Monitor patients’ This will ensure that Patients’ skin
impaired skin will remain skin continuously the skin is properly stayed intact
integrity intact with and educate the cared for, and any with no signs
related to no signs of patient and family abnormalities are of
immobilization inflammation on the importance promptly reported inflammation
device. or of regular skin and addressed. or
deterioration inspections, proper deterioration.
skin care
techniques and
signs of skin
breakdown.