#158 Achilles tendinosis treatment failures in a runner - DOC

#158 Achilles tendinosis treatment failures in a runner

Today on the Doc on the Run Podcast we’re talking about Achilles tendinosis that has failed multiple attempts at treatment.

Achilles tendinosis can be a tough problem. If you’re a runner who gets tightness in your calves and then develops Achilles tendinosis, it can be very difficult to get it to heal and it can be very frustrating.

This episode is based on a question sent in by a patient and he sent in this question and here’s what he wrote: “Hi, Doc. I love the podcast and hope you might be able to chime in on my situation with a future episode. I would love to hear your opinion. I’m a 41-year-old, 5′ 7″, 160 pound man who can’t sit still.”

“When I’m not in the office, I’m mountain biking, running cross country, skiing, snowboarding or playing with my kids. About five years ago, I began feeling tightness and pain in my arches and calves. Thinking this was just the price I had to pay for getting older, I experimented with different shoes and began stretching a little more. The pain in my calves continued to get worse when running and every run became a battle to fight through that pain. I continued to do this for about four years until I was unable to walk without pain. I finally visited a podiatrist in the spring of 2018.”

“An MRI showed no structural damage, but I was ultimately diagnosed with tendinosis of the left Achilles. I began laser therapy in his office, provided with custom orthotics and was put in a fracture walking boot for four weeks, followed by physical therapy three times a week over the summer of 2018. My right foot Achilles and calf improved but my left Achilles showed no improvement. I pulled myself out of physical therapy, continued some home therapy for the next few months, hoping it would heal on my own. After no improvement in my Achilles was shown, still can’t walk without pain, I visited my doctor again in the fall of 2018, where I was injected with amniotic stem cells and put back in the fracture walking boot for another four weeks.”

“Since then and throughout this past winter, I continued some home therapy including movements I’ve learned from you, but the pain is only getting worse. I visited my doctor again a couple of weeks ago and we now have a bone marrow aspirate scheduled for April, which will hopefully be the end of all this. Your podcast has taught me a lot, such as how irresponsible it was to not listen to my body early and stop when I feel that pain. I would love to hear your opinion on how I could have avoided this long-term issue and your take on different treatments and if I’m on the correct path now with the bone marrow injection. Thanks again and all the best.”

These are really great questions. They’re ones you should be thinking about if you’re injured and running. So, the first thing, of course, he wants to know my opinion on how he could have avoided this long-term issue. That’s true. Achilles tendinosis oftentimes becomes a long-term issue because you actually damage the collagen in the Achilles tendon. So, the first thing is, he did mention that he knew he was having pain for about four years. It was bothering him and it got increasingly worse to the point that he was noticing it and fighting through the pain during his runs. So, we all know that you have to have pain to work out and improve if you want to get bigger, stronger, faster, anything in terms of improving your athletic performance, but you should not have to fight through pain, particularly in one anatomic area when you’re training and when you’re running.

If you are, there’s a problem. So, he recognized that was a problem but thought it was just potentially getting older. Well, that’s one of the worst answers that you can ever get from a doctor. One of my close friends, we were on a bike ride one time. He had an issue with his hip. I told him to go see this particular guy who does hips and the next ride we were doing, he was actually really upset. I said, “So, Mike, what’s the problem?” And Mike said, “You’re not going to believe this,” he said, ‘Mike, you’re not 30 anymore.'” He could not believe that was the answer. And that, truthfully, is not a good answer. So, don’t attribute this to age. There are people in their 40s, 50s, 60s, 70s, even 80s doing ultra marathons.

They’re not fighting through the pain in their Achilles Tendon or their calf or their arch or anything else when they’re running on these long runs. So, you have to remember that age is not really the problem. I mean, it may modify some things. Yes, you may recover a little bit slower if you’re 70 than when you’re 30, but it’s not the age. So, it’s not just age. If you feel pain, don’t attribute it to just advancing age. That’s a cop-out. So, that’s the first thing. How could you avoid this? Well, the first thing is he noticed it started as tightness in the calves, right? So, one of the simplest things, obviously, is to make sure that the calf stays more pliable.

Why does the calf tighten up? I mean, a couple of problems, right? One of them is some sort of acute injury that’s turning into a chronic injury like the development of Achilles tendinosis. There’s also rare neuromuscular disorders where you get chronic tightness in the calf muscles, like Charcot-Marie-Tooth disease and some other things, but that’s completely different. It’s not the same kind of condition and this is not something that afflicts most runners and you would get diagnosed with that if you saw a doctor. So, we can just, at front, just let’s say, just eliminate all these rare, neuromuscular disorders but if you do not have some rare neuromuscular disorders and you’re getting tightness in your calves and you’re getting foot pain, you’re getting calf pain, you’re getting pain in your legs or some other specific area, you have to do something to address that.

Stiffness and weakness are the big contributors to those things for the most part. So yes, was it a bad idea to … Well, first of all, let me just qualify all of this and say, look, first of all, I appreciate you sending in your question. This is going to sound critical, but it is critical. You asked me to provide a critique on all these things. The first thing is that as you already recognize, it’s obvious that if you continue to run through pain for four years and you developed Achilles tendinosis, it got worse and now has become a chronic problem that’s being very difficult to treat, everything you did was wrong. That’s the bottom line.

I know that sounds harsh and that sounds kind of silly, but it’s true. So, we know for sure, that did not work. At the minimum, I would say that not running through that pain, not continuing to fight through the pain to where you really have to stop because it hurts so much, is the first thing. The second thing is to do something to address the tight Achilles tendon. So, the mainstay treatment, the primary thing that helps most people with a tight Achilles tendon, which doesn’t help all people with a tight Achilles tendon, when you get Achilles tendinosis is the eccentric stretches. We have videos on those. We can show you how to do them.

If you go to the bottom of the show notes for this episode, I’ll send you the video that shows you how to do it for free. I don’t really care. I’ll show you how to do it. You can try it if you want, but again, you have to try things and see if they work or not. And, for many people that have Achilles tendinosis who are runners, for reasons that I truthfully just do not understand, many runners don’t improve when they do eccentric stretches. But many non-runners and it seems to me, based on my experience, seeing runners and non-runners, it seems like many non-runners improve with the eccentric stretches, when they’re standing on a step, lowering their heel down. But many runners actually get worse.

One of the guys I saw who was a runner who was older who had Achilles tendinosis has probably sent more patients to me, referred more people to me than anyone else I’ve seen in my entire time in practice. He was a runner who, he went to the Mayo Clinic. He went to a number of very prestigious institutions. They told him to do the eccentric stretches for his Achilles tendinosis and he got worse and worse and worse and worse. Then, when I finally looked at him, I looked at all of his MRIs, I looked at all of his treatments, and I said, “Yes, you obviously have this, but if you look at your MRIs, all you’ve been doing for the last year and a half is eccentric stretches and you’ve been getting worse. So, I think we can now say that’s the wrong thing to do.”

He quit doing those. I gave him some different stretches to do and then he actually started to improve and he decided I was some kind of genius. But all I did was say, “Look, everything you did didn’t work. Let’s try something else.” And that something else happened to work. That’s the first thing is you know that all the treatments you did, did not help. So, the left Achilles was the problem in the beginning and even with all those initial treatments, including being in a fracture walking boot for four weeks and all of this other stuff that was tried didn’t really help. So, we know that running through the pain did not help. We know that continuing to try to fight through the pain did not help. We know that the Achilles tendons were tight and presumably, you weren’t really stretching to try to loosen up that Achilles tendon.

So, if we could go back to that period when this first started, not last summer, not the year before that, but at the very beginning when you started having difficulty, I would say at that point in time, the best thing would probably be to use the Equinus boot, which is the best brace on the market, in my opinion, to stretch out the Achilles tendon, to loosen up the Achilles tendon and it’s the easiest to use. Unlike a night splint that you have to sleep in all night, you only use this thing an hour a day. So, it’s expensive, but it’s extremely effective and I would assume that that would really help to loosen up the calf and get it moving again.

One of the things that happens, it’s sort of like it backfires. You get pain in your Achilles tendon. You get a little strain in the calf muscle. Something happens that causes that entire complex to try to lock up and protect it from movement. That’s why you feel stiffness. It’s trying to not move it. The problem is that when the calf is doing that, when it locks up, well, you still stretch it when you move because your foot’s moving up and down. That’s pulling the Achilles tendon on the back of your leg and that causes more injury. It aggravates it and it keeps getting worse and worse. But you have to loose it up and if you don’t move it, then you get indiscriminate scar tissue. You get cross-linking between those fibers in the Achilles tendon and they’re supposed to be trying to slide and they can’t slide anymore because they’re locked up with all that cross-linking.

That becomes a problem. Using something like the Equinus Brace to get that moving and to keep it pliable, I think could have averted all this disaster. Of course, we’ll never know, right? Can’t go back and do that, but that was my guess on what the initial thing was that could have helped prevent this problem. Also, if you have pain in the Achilles tendon during that time, inflammation is a huge contributor to this. So, doing something like icing, doing contrast baths, trying to do something to sort of arrest that inflammatory process that can damage the actual collagen in the Achilles tendon itself, probably would have been helpful. Again, we can’t go back and do that now, but I think that that probably contributed to some of the development of the chronic issues.

The next question is what is your take on all my different treatments? We’ve had a lot of different treatments here, right? So, this guy had a laser therapy in the podiatrist’s office. He had custom orthotics. He had a fracture walking boot. He had physical therapy. He was injected with amniotic stem cells. He was using a fracture walking boot for another four weeks and then he’s been doing home therapy. So, my take on those treatments is they didn’t work, so they were the wrong treatments. I know that sounds a little silly, but the fact is, is the reason this is an important question, is you have to figure out what you’re going to do next because if you’re not getting better, you’re going to have to do something differently.

Either you have to live with pain, live with decreased activities, stop running forever or figure out how to get it to work. Now, there is always a way to heal and get back to running, back to training, back to doing all the activity you want to do, but you have to figure out what’s going to actually work. Looking at the things that did not work and figuring out why they did not work, is kind of a crucial piece in terms of getting from where you are to where you really want to be. So, laser therapy, let’s talk about these quickly. Laser therapy can really help. So, laser therapy can stimulate new blood flow. It can help you heal for a lot of different reasons. It depends on which kind of laser therapy you had, but laser therapy does help a lot of people. It doesn’t help everyone. If it helped everyone, we would do it on everyone. 

Custom orthotics can also help. They basically change the way that your foot functions when it hits the ground, which theoretically, can decrease stress and strain on certain anatomic structures at certain phases of the gait cycle and it can help. But, not all runners need custom orthotics. I actually did a podcast episode on custom orthotics and why I don’t think that most runners actually need custom orthotics. Fracture walking boot for four weeks is one of the most common regimens recommended to runners who are just not getting better. The problem is … 

And, I gave a lecture on this recently in Lake Tahoe at a medical conference and I was talking about how the standard of care actually fails runners. Part of it is that things like fracture walking boots lead to a lot of different changes that affect runners: Decreased bone density, increased stiffness, increased weakness, loss of neuromuscular connections, decreased coordination. All of those things put you at risk of re-injuring once you actually start running. So, I’m not a huge fan of the four weeks in a fracture walking boot, but sometimes, it is necessary.

So, obviously, your doctor thought it was necessary if you did it, but clearly, it didn’t fix the problem. If you’re going to do that again, you have to think what are you going to do differently to help that actually work. The most common thing probably with fracture walking boots, why it doesn’t work, is that you’re not using it consistently. If you’re going to use a fracture walking boot, you need to really use it consistently. You have to do exactly what the doctor told you or you may not want to use it at all because if the doctor says you have to use a fracture walking boot, you need to use it all the time. You need to treat it like a cast. You need to keep it on 24 hours a day, but you take it off to drive to work. You take it off when you’re watching television and then you decide to get something to drink and walk across the living room to the kitchen. You figure what’s the difference? It’s just a few steps.

Well, that’s really not treating it like a cast at all. There’s a reason when we put casts on kids. Well, we don’t put on removable casts, right? Because they’re not going to follow directions. If you’re not following directions, that may be the reason it didn’t work. But, you have to figure out why that didn’t work. Physical therapy helps a lot of people. I had physical therapy one time for an extended period of time. That helped me avoid surgery. So, it does help a lot, but it doesn’t help anyone. But, if you do physical therapy three times a week throughout the whole summer and you don’t improve, you know that that didn’t help you.

But then, you have to try to figure out why. Was it something in the protocol that really wasn’t addressing the problem? Why exactly did that not work? Those are important questions for your doctor going forward. Why do you think each of these treatments failed? What was it, specifically, we could have done differently that would have helped this treatment heal my Achilles tendinosis? Another one is an amniotic stem cell injection. Amniotic stem cells are from a donor and we inject them into the tissue. So, lots of ways this can go wrong. There can be something wrong with the stem cells. They can not be thawed correctly. They could be injected into an area where the tendinosis isn’t most pervasive and so it doesn’t address all of the Achilles tendinosis.

There’s the whole thing with the protocol afterward. I’ve had lots of patients who will call me for consultations and I’ve had many of them who were going to have a stem cell injection. They’ll actually ask me if I can give them my protocol on what to do after a stem cell injection because I have high rates of success with stem cell injections. But, I can’t because I don’t know how the doctor did the injection. I don’t know what it looked like, many times and I don’t know really what is best to do because I don’t have any idea what’s going on with the patient. So, the protocol needs to be tailored, I think, to each runner. So, you can’t do one specific protocol for everybody.

If that worked for everybody, I would just go give lectures at conferences on this is what I do for everybody, but I don’t. You have to monitor and you have to see how you’re responding and you have to modify your protocol after the stem cell injection to make sure that you’re actually still continuing to heal and improve. If you’re not, you have to quickly change direction. That’s important. So, a fracture walking boot after the stem cell injection for a period of four weeks was another thing he tried. One of my main questions here is okay, well, why is it going to work? 

If you say well, you had a lot of damage, you used a boot; you used it, you followed directions, you did it for four weeks. That didn’t work, but it didn’t heal. Then you say, okay, well, the thing we’re going to do different is add a stem cell injection and then use a boot for four weeks, that is something different but you also really need to carefully consider why the fracture walking boot really didn’t help at all initially. Did it cause a different problem that contributed to the sort of recurrence of Achilles tendinosis or what’s the difference and what are you going to do differently in the treatment?

So again, I’m not a huge fan of four weeks in the boot, but obviously, your doctor thought that was necessary, so it’s important to figure out what you’re going to do differently going forward, if you’re going to do something similar. In-home therapy, so obviously, you tried a bunch of different things with home therapy, but not with any real improvement. So, you have to try to figure out what you could do differently. You have to shift things. So, if you have some improvement, you want to keep moving in that direction and keep capitalizing on those things that are helping. If you’re not improving, you want to stop the things that are making it worse. Many times, some things are making it worse.

One thing that hasn’t been talked about here is whether or not you used a heel lift, whether or not you altered your shoes, if you switched from one type of running shoe to another, what kind of shoes you’re using in the home, what kind of shoes you’re wearing to work. That may sound simple. But, the fact is that runners, as we learn more about technology, we learn more about these treatment training regimens like heart rate monitors and lactic acid threshold testing; all of these things that we think are high-tech that help us improve, it sort of steers us away from some of the old-school really simple things like the way that you run, your running form, the shoes that you use, how flexible they are, how stiff they are, how much rocker they have in the forefoot. 

All of these different things that actually are the interface between your foot and the ground, when you run, when you exercise and even when you walk in the home. So, you have to consider those things, too. Now, the last question, this really is the million dollar question. He wants to know whether or not he’s on the correct path now with the bone marrow aspirate injection. So, I’m assuming that this is basically a bone marrow aspirate injection in terms of trying to aspirate stem cells, in order to inject it, which is really a modified version of a PRP injection or a stem cell injection that he had before.

So, I’m assuming that the previous amniotic stem cell injection was from a donor and in this case, the thing that’s being done differently is just taking the stem cells from the bone marrow and trying to inject those into the Achilles tendon. You have to think about what didn’t work. Why did it not work before? Why might it work this time? So, if you don’t do anything differently and the only thing you change is the type of injection, given all the other treatments that have been tried, I think it’s unlikely that it’s just going to fix it. You can cross your fingers and hope so, but you have to really think very carefully about what all you can modify. So, some of the things that have not been discussed at all here are how much you sleep, how much you hydrate, what your nutrition is like, whether or not you’re doing any kind of collagen supplementation, whether or not you’re doing anything to reduce the amount of stress in your life. 

Now, I know those are things that most runners don’t want to address, but they are contributors to your overall healing process. Whether or not you’re taking aspiring, whether or not you’re taking non-steroidal anti-inflammatory drugs, whether or not you’re taking fish oil capsules, all of these things can actually decrease the effectiveness of a stem cell injection, a PRP injection, a bone marrow aspirate injection. All of those things can affect the healing process. So, the first thing is to talk to your doctor and ask all of these questions. 

Say, “What is it? Why really, did I not improve with this previous stem cell injection?” If the doctor says, “Well, I think that there was something wrong with the stem cells or something wrong with the process of the stem cells that made them not effective for you and we’re going to bypass that by using your body’s own stem cells.” That seems like a valid answer but again, when you get stem cells from a donor, theoretically, you have many, many, many times the number of active stem cells in there as opposed to when you take the bone marrow aspirate from an adult. That’s just a fact. So, statistically, if you’re trying to get the number of stem cells up, taking it from yourself, it may be more bioavailable because you haven’t frozen them and you’re not thawing them again, but it’s fewer numbers of stem cells. 

So, you have to talk to the doctor and figure out why the doctor actually believes that this is going to make a difference for you. That’s the key here. Then, you have to figure out what are you going to do different? How are you going to change the protocol because if it’s another four weeks in the boot, I don’t know. We’ve already had two episodes of four weeks in a boot and it didn’t improve. So, is that really necessary? Is that really helpful? Is there some thing that we should change about that protocol? Should I maybe use a Bledsoe Achilles boot in order to take some of the stress off the Achilles tendon instead of using a normal fracture walking boot?

What is something that we can change? What is something we can do differently going forward to optimize the chances that this treatment is actually going to work? Those are really the keys when you get an Achilles tendon issue, like Achilles tendinosis and you’re a runner and you’ve tried virtually everything under the sun, but you’re just not improving. You have to change something if you expect to get better and get back to running.

Equinus Brace

I believe the Equinus Brace is the best brace to address a tight Achilles tendon in runners. I really believe that 100%. And if you have a tight Achilles tendon (like pretty much every other runner) if you have plantar fasciitis, the Equinus Brace thing is so much simpler and easier to use than any of the other braces or night splints on the market. And truthfully, the Equinus Brace is much easier to use consistently than just doing the stretches. So get it today!

All you have to do is go to the Equinus Brace website https://www.fixequinus.com then enter our special discount code DOCONTHERUN (all one word, all caps). When you enter DOCONTHERUN in the discount code box, they will give you free shipping. 

I believe the Equinus Brace is the best brace to address a tight Achilles tendon in runners. I really believe that 100%. And if you have a tight Achilles tendon (like pretty much every other runner) if you have plantar fasciitis, the Equinus Brace thing is so much simpler and easier to use than any of the other braces or night splints on the market. And truthfully, the Equinus Brace is much easier to use consistently than just doing the stretches. So get it today!



If you have a question that you would like answered as a future edition of the Doc On The Run Podcast, send it to me. And then make sure you join me in the next edition of the Doc On The Run Podcast.