Friday, November 25, 2016

Friday, November 18, 2016

A primer on achilles tendinopathy and first world problems

This past week I traveled to Umeå, Sweden to have surgery on both of my achilles tendons by Dr. Håkan Alfredson at The Alfredson Tendon Clinic.  I've always found runners' seeming voracious interest in talking about their injury woes to be somehow embarrassing.  I mean, come on, it's just running.  Yes, I'm going to do exactly that here in suffocating narcissistic detail.  It will be pedantic for you, cathartic for me, and hopefully helpful for one guy or gal out there struggling in similar fashion.  Let's do this! 

Achilles tendinopathy is a common injury in runners.  It is also a frequently misunderstood condition. I've struggled with chronic mid-portion achilles tendinopathy in both lower legs, right worse than left, for approximately 10 years.  While other runners talk about 'injuries' plural, my running career has been defined by 'injury' singular: it has been the predominant limiting feature in terms of my athletic endeavors and ambitions (I suppose other than a mediocre genetic endowment and modest VO2 max).  Cue tenuous Trojan War metaphors here.  Over this past decade I've not only tried a range of treatment modalities but I have also become a bit of an armchair student of the condition.   

My achilles woes began when I was 28 years old and attempting to run marathons fast (everything is relative guys).  I was in medical school training 100-120 miles per week and saw fit to augment this work load (and academic schedule) with some strength work.  Of course, this corresponded with clinical rotations that often had me in the hospital and on my feet for 80+ hours per week.  I recall getting up at 2:00am to fit in a 12 mile run before I had to be at surgical rounds at 5am, and then running again late at night upon returning home to get in a double and keep my mileage goals for the week on track.  Not a lot of sleeping going on: clearly not a recipe for long term health and injury resilience.  One fateful day I decided to start doing calf raises and almost immediately my R. achilles became sore and swollen.  Of course, like any self-respecting 28 year old male I continued to stubbornly train through this for months, icing multiple times per day.  By that summer I was having trouble walking and the writing was on the wall.  Long story short, I took up road bike racing and didn't run again for 3 years.  The details since that time are not particularly unique.  Any period of prolonged running resulted in increasing amounts of pain and dysfunction, bilaterally but R >L.  For a long time I would respond by taking long hiatuses in running so as to heal, only to return, start getting fit again, and then again be crushed by recurrent pain.  About 5 years ago I decided I would no longer stop running: it was clear this problem wasn't going away and I was resolved to manage it as best I could and no longer miss out on events and projects I was excited about.   All in all, I've managed to rack up some good adventures with this strategy and have no regrets.  The list of treatments I've done includes but is not limited to:

-Extended time off (3 years as well as multiple stints of 1-2 months).
-Eccentric heel drop protocols 
(Originally proposed by Dr. Alfredson as it turns out. I've done countless permutations on these for 10 years.  They remain the mainstay of conservative treatment protocols for chronic midportion AT (insertional AT is a different beast and these exercises probably worsen it unless modified).  If you struggle with AT this is a do-not-pass-go intervention with a high success rate (people NOT to pay attention to in this regard include Joe Uhan who wrote a well-meaning but uninformed piece on iRunFar several years back).  (1)
-Night splinting
-Night splinting + eccentrics
-PT (focusing on balance, proprioception, calf and soleus strengthening, gluteus strengthening, flexibility, anterior tib strengthening, and anything else that seemed reasonable)
-Extensive gait analysis on force plate and video biomechanical analysis with targeted PT
-Yoga, flexibility work
-heel lifts, minimal shoes, maximal shoes, zero-drop shoes, barefoot running
-Regular deep tissue massage 
-Nitro-Dur patches
-Dry needling (soleus, gastroc, anterior tib, glutes)
-Supplements/Meds: NSAIDS (both topically and orally), glycine, glucosamine, Vit C, bromelain, turmeric, ginger
-Diet changes (yeah, I'll even grudgingly admit I tried low-carb thinking it might lower inflammation.  no dice.)
Notable treatments I have NOT done include: corticosteroid injections (increased risk of AT rupture), PRP (poor evidence base), sclerosing injections (decent evidence base), extra-corporeal shock wave therapy (fair evidence base), religious prayer (no evidence base).  

I'll offer the side observation here that physical therapy assessments are a mixed bag.  (A good PT is worth their weight in gold however).  The happy fact about  'kinetic chain' arguments as they pertain to biomechanics is that they offer a seemingly infinite array of possible shifting explanations.  Establishing causality here proves tricky however. The modus operandi of the physical therapist is that pain in one part of the body is always related (at least in part) to dysfunction occurring elsewhere.  On the surface this statement is trivially true: human locomotion is incredibly complex and involves multiple coordinated muscle groups, bones, fascial planes, nerves.  However in practice this set of arguments plays out much like the similarly non-falsifiable arguments promoted in psychoanalysis ("Your problems are related to your mother." "But I have a great relationship with my mother!" "You are clearly sicker than I thought, in huge amounts of denial, and will need to come 5 days a week indefinitely.")  I've had therapists identify the 'source' of my achilles pain in my hamstrings, my ankles, my glutes, my mid back...  In the back of my mind I always thought: "I can tell you exactly where the goddamned problem is.  Right here! (vigorously pointing to my achilles)."     

Over the past 5 years I've been able to consistently train by doing the following:

1. Radical activity modification.  
This involves basically very little if any running to speak of and exclusive focus on power hiking.  I've trained for and run a number of hard mountain 100 mile races by doing 25-35,000 ft of vertical climbing per week and no running except downhill and infrequent races. 
2. Regular deep tissue massage focusing on calves, hamstrings primarily.  q2 weeks or so in heavy training periods.  (I have worked primarily with Shannon Herzog and Emma Maraanen who are both excellent and have been very helpful.)  Combined this with daily mobilization and self-massage on a foam roller as well as proprioception work for ankles.  Continued PT work through the Univ. of Utah Running Clinic with Laura LaMarche (who is excellent). 
3. Off-season intensive eccentric exercises
focusing exclusively on bent-leg eccentrics given that straight leg eccentrics rapidly worsen my pain, as I'll talk about.  These would increase my pain for the period of months that I would do them but would allow me to train with reduced pain through the first part of the running season.
4. Lower extremity strength work (glutes mostly)
5. Gait retraining: naturally a forefoot striker I've trained my self to run with a heel-strike, which definitely has helped.  
6. Very little if any work at sustained high intensities. (Not ideal for training purposes but any day I did that was particularly long or particularly hard I'd have to take 3 days off.)

With this regimen I've been able to hold things together so to speak.  But there has not been a single run I've had in years without pain and the net effect of doing this much 'managing' is that running- if this can be called running- has become significantly less fun.  Each morning is spent with about 90 minutes of hobbling around.  I truly love climbing steep mountains, but I also love the pure and simple meditative act of running, even if this is around a 200m track.  Looking at the above list of machinations I've gone through the natural recommendation is clearly dude, just pick up a different sport!  Yeah, I've tried.  Running is in my blood.  Post Hardrock on our trip to Vermont and Maine I attempted a mellow (9min per mile!) 6 mile run and was completely hobbled.  It started sinking in for me how limited my activity has been by necessity and I started researching surgical options again.  

I've been aware of Dr. Alfredson's work for a number of years.  I had in fact looked into surgery several years ago but hesitated (this is a guy who has trouble justifying taking a single ibuprofen after all).  Surgeries for chronic achilles tendinopathy have historically involved large open procedures with multiple longitudinal tenotomies of the tendon itself and prolonged post-surgical immobilization and recovery.  Only in the last 5-10 years has there been more investigation into minimally invasive procedures.  It turns out that tendons are pretty weird.  There is not a well established relationship between actual tendon pathology (on direct inspection or ultrasound) and level of pain/dysfunction.  In fact, much current research suggests that chronic achilles pain has little to do with tendon structure itself and much more to do with ingrowth of sensory fibers and small vessels in the peritendinous connective tissue and fat with ingrowth into the paratenon(2).  Insofar as prior massive tenotomies achieved success, perhaps this had more to do with disruption of these nerve fibers and vessels.  This is the guiding principle for many of the current surgical approaches to achilles tendinopathy.  Dr. Alfredson, among others, has focused on the relationship between achilles tendinopathy and the plantaris tendon- a small, insignificant 2-joint muscle and tendon that assists in plantar flexion.  The plantaris tendon runs medial to the achilles in a majority of cases and inserts into the calcaneus.  In a significant number of individuals with chronic midportion AT there is contributing plantaris dysfunction: the tendon can become adhered to the achilles or can invaginate into the achilles itself, predisposing the runner to chronic compressive/shearing forces and irritation leading to chronic inflammation and pain.  In fact, a significant number of chronic AT cases have ONLY plantaris tendinopathy with normal achilles structure.  

I thought there was a good chance that I had plantaris involvement for a number of reasons: a) it is increasingly recognized as a common cause of treatment-refractory AT, b) straight leg eccentric exercises have always dramatically worsened my pain (classic for plantaris related conditions), and c) my tendons themselves- while thickened- have never shown classic tendinosis (3) like changes on imaging (ultrasound or MRI).  

Interestingly, there are no surgeons (that I know of) in the U.S. that focus on plantaris excision as part of AT surgical interventions.   Dr. Alfredson was my man.  Tickets to Sweden were booked.  

We spent a week and had a great trip exploring the country.  We rented a car and drove all around from Stockholm to the Dalarna region and ending up in Umeå which is in close proximity to the Arctic Circle.   The highlight for Ada was losing a tooth and having the tooth fairy travel all the way to Falun, Sweden to deliver her some gourmet chocolate.

The procedure confirmed my suspicions: my plantaris tendons were closely adhered to the achilles bilaterally with significant vascular ingrowth in the peritendinous tissue.  On the right side the plantaris had slightly invaginated into the achilles tendon sheath.  My achilles tendons themselves were thickened but didn't look that bad all things considered. 

Dr. Alfredson, his wife Lotta, and his office staff were a true pleasure to interact with.  I had a ton of questions (that I had prepared beforehand, after all, this guy is THE achilles tendon expert) and Dr. Alfredson took large amounts of time to discuss these with me.  The procedure went well and I'm in the process of recovering at home now, fingers crossed.  

I'd be happy to discuss any of the above as well as the logistical and financial math involved if you are interested. (Suffice it to say it was surprisingly cheap to have this done in Sweden paying out of pocket). You can just comment here and I'll get back to you.  

(1)  It has been argued that eccentric exercises work by stimulating collagen remodeling in damaged tendons.  These typically specify 'heavy load' eccentric training which are quite painful and can initially worsen symptoms before there is improvement.  There is good reason to think that the typical protocols (3 sets of 15 reps three times per day) is insufficient in high level athletes and people have argued for as much as sets of 90 reps.  It remains unclear why exactly eccentric training works.  With eccentric work small neovessels in the achilles complex are constricted and one idea is that perhaps with ongoing training these become ablated (along with sensory nerves).  

(2) In fact, it seems like there is good reason to think that many of the pathologic changes that occur in chronic tendinopathies are centrally-mediated with some degree of neurogenic inflammation.  One study showed that for individuals with bilateral AT, surgerizing only 1 side resulted in resolution of symptoms AND resolution of pathological changes in AT structure on imaging on BOTH sides!  (See Christopher Spang (2015). The plantaris tendon in relationship to the achilles tendon in midportion achilles tendinopathy.)  So maybe it is all in my head afterall...

(3) 'Tendinosis' refers to pathological changes in tendon structure that are not inflammatory and are more characterized by nodular swelling of the tendon, dysregulated collagen arrangement, and hypoechoic areas on ultrasound.  This term is used to denote the fact that most chronic tendinopathies do not appear to involve acute inflammation (the '-itis' of tendinitis).   



The Vasa Museum. Truly incredible and worth a visit if you are in Stockholm.

Exploring Stockholm.

The Royal Palace.

Royal Palace living quarters

Nordic Museum, Stockholm

Breakfast at the Pop Hotel / ABBA museum. Guess which one is the dancing queen?

View of my achilles and former plantaris tendon.
Interesting challenges on the long trip home.

Here are a few relevant articles if you are still interested in learning more:

#Christopher Spang's extensive characterization of plantaris involvement in AT:

#Causes of pain in AT:

#Review on AT treatment:

Alfredson H, Pietila T, Jonsson P, Lorentzon R (1998) Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 26: 360-366.

Alfredson H, Thorsen K, Lorentzon R (1999) In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Knee Surg Sports Traumatol Arthrosc 7: 378- 381.

Alfredson H, Ohberg L, Forsgren S (2003) Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis? An investigation using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Knee Surg Sports Traumatol Arthrosc 11: 334-338.

Alfredson H (2011a) Ultrasound and Doppler-guided mini-surgery to treat midportion Achilles tendinosis: results of a large material and a randomised study comparing two scraping techniques. Br J Sports Med 45: 407-410.

Alfredson H (2011b) Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med 45: 1023- 1025.