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.


  1. Dear Dr. Lewis: This is a fascinating post. You have scientific curiosity, medical training, a love of running, and a remarkable sense of humor. You have followed a long and winding road. What advice can you give me about resolving the plantar faciitis (one stop further down the chain) in my left foot? I thought I had it licked, but the nine weeks off, various therapies under the direction of a DPM, etc., similar to some of what you described, unfortunately did not result in a cure. My DPT daughter and my Cardiac Critical Care RN daughter suggest improving blood flow, PRP (you don't seem to be a fan - above), massage, toe splay, careful balance of strength training. I am 57, in excellent health, but tall and therefore heavier than avg. runner. I used to do 6-7 miles/day and miss it terribly. Any suggestions? We toured Denmark on a trip to visit my daughter (now the DPT) a few years ago. Northern Europe is marvelous, isn't it? I look forward to good news about your AT in subsequent posts. I will forward this post to a friend of mine in our local running club who has chronic AT. Thanks for posting.

  2. Hi John,
    Thanks for your kind words! Sorry to hear about your struggles with plantar fasciitis. I've dealt with only mild cases of PF in the past and symptoms responded to a combination of night splinting, rigorous calf stretching, and rolling out my feet on a golf ball. I believe there has been some evidence supporting PRP as well as extracorporeal shock wave therapy (small studies)- those might be good options for you. I have also heard of people having good success switching over to maximalist footwear with plenty of cushioning (Hokas). Best of luck, hope that you find some solutions. Ben

  3. HI Ben- I also live in SLC and just stumbled on your post. I, too am seeing Laura Lamarche and like her. I have only had AT since September ( a result I believe of too many Runs up Mt. Olympus near my house). I just took 2 weeks off running with lots of skiing and biking and stair climbers in the interim. I tried a 5 mike road run Sat with no pain, then dumbly tried a 7 mile run in the snow on the BoSho on Sunday and the pain is back. I have had Plantar F before and it took almost a year to heal. One think I noted about the PF is that it did not get better with no running. I had to run gently through recovery process. I suspect the same might be true of AT but I'm scared of turning it into a chronic case. What are your thoughts on continuing to run, gently, not too long and on controlled surfaces through this? Is it your experience that speed hiking and skinninig, etc don't make it worse? Also- is it necessary to load up some weight and done tons of reps for teh eccentric heel protocol to work? Thank you for any further insight you might have! Your article is absolutely the best I have found. I wish you speedy and sucessful recovery from you surgery. I hope it works!!

    1. Hi Jon, thanks for reading- I'm just reading your comment now. I wonder if a more gradual re-introduction of running, and on firmer surfaces, might have fared better for your achilles. The softer surface of the snow could have added increased strain on the tendon. I found that hiking and skinning didn't make my situation worse: the surefire way to fire things up for me was to try anything quicker on flatter surfaces. What seems to be the case for eccentric exercises in higher level athletes is that you need more intensity. I would suggest trying to increase your reps. I've never found full on rest to be helpful for any running injury other than stress fractures. Best of luck, let me know how it goes!

  4. Hi Ben,
    Best wishes for a good recovery and many miles of running in your future. I'm really confident that you will be happy with the results of your surgery.
    I read your blog with interest partly because I too just had bilateral achilles surgery from Dr.Alfredson at the end of October! I live in Seattle and was more than happy to fly to Sweden for this surgery since based on my research Dr.Alfredson is "the" man when it comes to Achilles tendinopathy issues.
    Did Dr.Alfredson do any work besides excising your plantaris tendons? In my case he removed my subcutaneous and retrocalcaneal bursae in addition to the plantaris tendon on both sides.
    I am so happy with how my recovery has gone so far. I'm looking forward to start running again in a few weeks.
    Thanks for the post.

    1. Hi Stefan, this is great to hear that you have been happy with your recovery thus far. Sounds like you were there just a couple weeks before I was! Dr. Alfredson just excised the plantaris tendons and then scraped the ventral side of the achilles but left the bursa intact. I'm definitely making progress and have done some easy running. Hiking is fine and I've done some approx. 1 hour hikes jogging down the mountain. I still have some significant swelling on both sides and am pretty stiff, primarily in the mornings. I've been able to ride a stationary bike and elliptical without pain and have done some skate skiing that has been fine as well. Keep in touch - it will be fun to compare notes.

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  6. Dear Dr Lewis
    I was really interested to read your blog, I've been through 3 years of trying everything but continually breaking down and finally it seems the plantaris tendons may be the issue. I've had scans and now have an appointment with Prof Alfredson and then may have surgery on one or both achilles tendons. I'm interested to hear how is your progress going post op, and how long did it take after the op before you could get onto your feet again?

    1. Hi Sandy, I'm very pleased I had the surgery. I was walking (albeit slowly and in very limited fashion) the day after the procedure. I flew home to the US the following day which was probably not ideal as far as recovery- I experienced a lot of swelling that took a while to go down. The following week I was back at work and was moving about very slowly, but walking nonetheless. I was surprised by how painful it was for the first 2-3 weeks post-op and how limited my ROM was. I was riding a stationary bike (gently) after 1.5 weeks and then progressed to the elliptical at about 2 weeks. I'm now about 11 weeks out and I'm happy with my progress. I'm going very slowly with reintroducing significant running and have been mainly skate skiing and backcountry skiing, running maybe 20 miles per week max, all very easy at this point. I've overdone it a couple times with some resultant swelling so I've made it a priority to just be patient. Despite this, I'm definitely better now in terms of pain than I have been for a long, long time. Glad to hear you are considering seeing Dr. Alfredson! Best of luck and let me know how it goes.

    2. Hi Lewis
      thanks very much for this, great to hear you are doing so well,, I'll let you know how it goes, potential op in early March after appointment with Dr Alfredson

  7. Hi Lewis
    had the bilateral excision and scraping procedure yesterday by Dr Alfredson. Apparently I had an unusual (not seen before!) variant where the plantaris was positioned right on top of, and growing into, the achilles. So he excised on both legs. Now to start the re-hab and hopefully back to running in a couple of months. How is your progress going?

    1. Hi Sandy,
      Glad to hear you made the trip! Good luck with the recovery process. I experienced quite a bit of swelling a stiffness post procedure that lasted longer than I expected but was riding a stationary bike at around 2 weeks after the operation. I still have some swelling, particularly after running, but am running between 1-2 hours 4-5 times per week now with significantly reduced pain compared to pre-surgery. I initially tried to ramp up my running too quickly and since then I've taken the long view and will probably hold off on any races until fall. Very happy I did the procedure. Good luck to you and stay in touch with your progress! -Ben

  8. hi Lewis
    thanks for your update. Did your stiffness result in some pain in the Achilles? I still have some pain on the left (worse) side, it comes and goes when I walk, and I'm hoping this will settle down. Otherwise progressing well, now 2 weeks post op - doing some stationary bike work, walking slowly and gentle exercises. Great to hear you're planning to get back to racing in a few months - definitely my goal as well.
    All the best

  9. Hey Ben, circling back on this great post. There is a song called "Tendons" by my favorite indie rock band The Joy Formidable from Wales. I am hosting a "Name That Song" quiz on the fan page and I used Dr. Alfredson's clinic location (in a roundabout way) as the clue for today's quiz. I hope you and the family are doing well.

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