Doc On the Run Podcast: There Is No Key To Healing. It's A Combination. | DOC

There is No Key to Healing. It’s a Combination.

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Today I was on a 15 minute Virtual Doctor Visit call with a runner who has been trying to get over a nagging case of Achilles tendinitis and still wants to do well in the Boston Marathon.

It may not surprise you to hear that he is worried about how skipping long runs to protect the Achilles tendon will make it very difficult for him to have a good run in Boston.

He’s been doing all the right stuff. He has taken the right steps to remove the inflammatory fluid around the Achilles tendon. He’s been doing the right supplementation routine to help rebuild the collagen. He’s been doing the right workouts to help break up cross-linking and reorganize the collagen alignment in the Achilles tendon.

He has been improving but, he had very mild setback, got a little swelling and it made him worried. So, he just wanted to have a quick call to talk about his progress and figure out whether or not he needed to stop running or shift to some different activity.

In 15 minutes we were actually able to come up with several different ways he could augment his training to add some longer workouts that wouldn’t put as much stress on the Achilles tendon.

After I got off a call with him I started thinking about how I could take the information I shared with him and then make it available to anyone like you listening who may have a similar problem.

I was thinking really carefully about what exactly it was that I told him, what really helped to shift his direction to come up with a new strategy to better maintain his fitness and preparation for Boston.

We talked about how much improvement he had in terms of the swelling going down. We talked about how the Achilles tendon was feeling when he was running. And we talked about how much running it took before he started noticing discomfort.

When I was trying to figure out how I could take those exact recommendations and apply them in a more general sense to anyone with an Achilles issue, or a stress fracture, or plantar fasciitis, I realized that there is no one standard routine that will work for everybody.

In fact most of the value in the call was not explaining how to make the Achilles tendon better for this one particular runner. The real value was in taking his unique circumstances and helping him understand how his decreasing and increasing swelling shows him exactly how much stress is acceptable and how much stress is unacceptable.

Once we talked about all of his symptoms and figured it out, it was very easy to come up with a specific routine that would combine a number of different types of workouts that will allow him to do long runs, maintain his aerobic fitness and still continue to rebuild and repair the damaged Achilles tendon.

But it takes a combination. There is no one single key. There is no magic pill. And there’s certainly no one magic pill that will work for everyone.

If you have a stress fracture and you call me, we will talk specifically about how much your foot hurts when you’re running. We will talk about how much it hurts when you’re just sitting still. We would even talk about how much your foot hurts when you’re just walking.

I would actually look at pictures of your feet and help you understand how to recognize whether or not there’s any subtle swelling that could signify ongoing tissue damage or a repair process.

Depending upon those factors, I would recommend different ways to decrease the pressure on that specific metatarsal just enough so it will continue to heal even while you increase your activity level and run more.

But it all depends on what’s going on with you. Your situation is unique. Your biomechanics are unique. And the extent of damage in your metatarsal stress fracture or your Achilles tendon or whatever else is bothering you is also unique.

The problem is that everyone including doctors, seem to want to have one specific treatment that works for all patients.

We even have a name for it. We call it the “Standard of Care.”

The more I work with runners and the more I lecture to physicians at medical conferences about advanced strategies for healing runners, the more I think the idea of a “Standard of Care” is complete lunacy. Runners need something better.

Think about last time you went to the doctor. Whether you went to the emergency room or you saw your regular family practice doctor there is a good chance that at the conclusion of your visit the doctor handed you an information or instruction sheet that had already been prepared.

Do you think she typed that up just for you? Of course not.

She typed that sheet up 11 or 12 years ago, for you, and the 83-year-old woman who slipped and fell in her bathroom. And the 12-year-old boy who rolled his ankle playing soccer. And the middle-aged, sedentary office worker who slipped on the ice walking to his car the other morning. Your doctor gave that same sheet to everybody with as similar injury that day.

But just because your injury may be similar to all those other people sitting in the waiting room your injury is not the same.

So what are the chances that instruction sheet you got (that is supposed to be written just for you) is actually going to be right for you?

Believe it or not there have been a number of scientific research articles published in medical journals discussing and debating the difference between specific individualized instructions and pre-formatted prewritten discharge instructions.

There was actually an article entitled “Discharge instructions for emergency department patients: what should we provide?”

As a runner what sort of instructions do you think you should get? Do you think it would be better if your doctor actually explained what was going on with you, and then gave you specific recommendations on how to maintain your running fitness? Do you think you would do better if you got that kind of individualized instructions?

Or, do you think you get better if you just got the same instructions as that 12-year-old boy and that 83-year-old woman?

Believe it or not, this particular review article argued that individualized hand written instructions “are likely to lack structure and some desirable features…and their usefulness may be limited by poor handwriting. Consequently, their adequacy may be suspect in many cases.”

Okay I will openly admit that my handwriting sucks. I’m a doctor. My handwriting is supposed to be terrible. But I will tell you that messy handwriting is not an excuse for not giving a runner individualized advice.

No matter how bad my handwriting might be, I’d be willing to wager $1 million that my hand written instructions will be better for that particular runner than any pre-formatted instruction sheet handed out from any emergency room anywhere in the world.

You have to be able to talk to your doctor and figure out where you are on that continuum of injury. You have to figure out where you are on that continuum of healing.

Every overuse running injury has a range of trouble. You have to know where your injury is within that range. That’s how you can know how much running you can do and still heal.

Many doctors will tell you that a stress fracture is just a crack in the bone. And since it is just a crack in the bone, and we think we know how long it takes to heal bone, doctors will tell you the same thing in terms of how long you have to stop running and how long it’s going to take you to heal.

A stress fracture isn’t even a crack in the bone in most runners. It’s too much stress in the bone that caused inflammation inside the bone. That’s what’s really going on in most of the runners I see. Then bone isn’t really broken. If it isn’t really broken, you certainly shouldn’t spent six weeks in a fracture walking boot.

Achilles tendon problems have a whole range of trouble as well. But doctors want to pigeonhole those things into pre-formatted instructions and fixed timelines also.

“You need to take six weeks off running.”

“You have to stop running for three months.”

These are things doctors will tell patients without even considering where they are on that continuum of healing. I don’t think it’s really even true for most runners.

If you just have a little bit of swelling around the Achilles tendon that definitely is not going to take as long to get better as someone who has a partial tear in the Achilles tendon.

Even if you’ve been diagnosed with chronic Achilles tendinosis there’s a range of trouble with that as well.

Trust me, if there was one solution that would work for everyone, I would put it into a five minute course and provided it for you. But you can’t explain that range in five minutes. That’s why your five-minute doctor visit doesn’t work for runners.

You need to be able to explain your specific symptoms, correlate them with the activities that you’re doing currently, and the activities you need to do, the runs you need to do in order to maintain your fitness and show up on the starting line of your goal race ready to run.

Race day is coming. And trust me no matter who you are, they’ are not going to change the date of the Boston Marathon just because your Achilles tendon isn’t ready on that particular day in April.

So you have to get the right advice. You need to right advice for you.

There is no key to healing. It is a combination.

If your doctor hands you an instruction sheet and suggests it’s the key to healing, tell her you need a combination instead.

References:

Discharge instructions for emergency department patients: what should we provide? Cameron P, Taylor D.  J Accid Emerg Med 2000;17:86–90

If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!

Dr. Christopher Segler is a podiatrist and ankle surgeon who has won an award for his research on diagnosing subtle fractures involving the ankle that are often initially thought to be only ankle sprains. He believes that it is important to see the very best ankle sprain doctor in San Francisco that you can find. Fortunately, San Francisco has many of the best ankle sprain specialists in the United States practicing right here in the Bay Area. He offers house calls for those with ankle injuries who have a tough time getting to a podiatry office. You can reach him directly at (415) 308-0833.

But if you are still confused and think you need the help of an expert, a “Virtual Doctor Visit” is the solution. He has been “meeting” with runners all over the world and providing just that sort of clarity through online consultations for years. He can discuss your injury, get the answers you need and explain what you REALLY need to do to keep running and heal as fast as possible.

You can arrange a Virtual Doctor Visit with a true expert on running injuries. Right from the comfort of your own home you can meet online with the doctor, discuss your running history, talk about your running injury and figure out a customized recovery plan that will help you heal the running injury so you can get back to running as quickly as possible.

Book your Virtual Doctor Visit with Doc On The Run now!