Let’s start with the stats: Male, 48, 5’9″,
210 lb, 1RM for press 215 lb, bench 350 lb, squat 455 lb, dead 485
lb, and I’ve missed 500 lb six times in the past 3 years. For the
past 5 years or so all I have done for exercise are the four main
barbell exercises. I’m not sure why my right Achilles started
hurting, but it must have started about two years ago. Maybe I was
running a bit in the dog park while playing with the dog, but I had
no single moment where I remember it grabbing me.
This also happened
about 13 years ago when training for a marathon, and I was able to
rehab the tendon using eccentric heel drops and return to marathon
prep.
A bit of history about
tendon remodeling and recovery: In the 1990s, Dr. Håkan Alfredson
was a surgeon in training (in Sweden) and aggravated an Achilles
tendon (AT) due to running. He asked if he could get a surgery to
treat the tendon prior to a rupture, but the supervising surgeon
refused since the injury wasn’t severe enough and the understaffed
clinic couldn’t get him the time off. Alfredson then went to the
gym to load his tendon beyond any reasonable measure, according to
the standards at the time, in an attempt to rupture his tendon. About
a month later, he was able to run again.
This led to the insight
that tendons could be remodeled. There is a significant
difference between acute inflammation and chronic changes associated
with a tendon after injury, and many papers have been written on the
topic. Terminology has been defined as “tendonitis” representing
the acute phase of injury and “tendinosis” or “tendinopathy”
as the chronic condition. Without the proper stimulus for healing,
the tendon will be in a chronic state of breakdown and failed
healing.
Why does tendinopathy
occur? Specific causes could be mechanical, due to uneven forces due
to intrinsic factors such as anatomical abnormalities, age, muscle
weakness, or extrinsic factors such as overuse and training errors.
One theory is that the tendon requires relatively little oxygen
compared to skeletal muscle and this is demonstrated via a lower
metabolic rate in the lower tissue. However, the low metabolic rate
results in slow healing after injury.
The solution for
recovery: eccentric loading. Tendons have been shown to respond to
load via mechanotransduction, causing an upregulation of insulin-like
growth factor (IGF-1), which is associated with cellular
proliferation and matrix remodeling. Doing eccentric loading is the
lowest metabolic requirement for a tendon, hypothetically causing
fewer side products from cellular metabolism which have been
implicated in chemical irritation of nerves.
Alfredson’s initial
protocol was quite successful in several studies; it was 3 sets of 15
reps of bent-knee and straight-knee calf raises (45 bent, 45
straight), twice a day, 7 days a week for 12 weeks. Work through pain
unless disabling, and continue to increase load by 10 lb once body
weight/current load was pain free.
What about me? A couple
of years ago I set out to do my heel drops, and it kept getting
worse. Less than 20 reps caused me considerable discomfort, and I
limped all the time due to the pain during forced plantar flexion. I
went to a sports physiatrist, as I was sure the tendon was torn.
Using ultrasound, she found the tendon was not torn, but had lots of
swelling in the AT insertion on the calcaneus. She gave me several
options for treatment. As I am a physical therapist, I opted for
physical therapy, thinking someone might have a more objective view.
I gave it about five
visits over a month with no significant improvement. There were times
I felt I was getting better, but I’m wondering about the loading
program. It seemed to me an optimal treatment session would be some
“massage” (actually a scraping-type technique), attention to my
form during heel drops, and a loaded calf machine, and when this was
the treatment I felt better. But I was scheduled with the therapist
for an hour, and all professions need to stay billable, so for
another 30 minutes she had me do a lot of other exercises; such as
walking on my toes for multiple laps in the therapy clinic (probably
too many reps for the tissue).
When I went back to the
MD for other options, she suggested prolotherapy over platelet rich
plasma (PRP) injections. Neither were covered by insurance (of
course), and PRP injections were $800 and required a few weeks of
non-weightbearing, followed by additional weeks of relatively low
activity for optimal outcome. Pretty tough, when I walk around a
hospital all day at work. So I agreed to try the prolotherapy. It
consisted of a dextrose solution injected into the tendon while being
viewed on the ultrasound. She would inject along the tendon in
multiple places and also attempt to tease the tendon away from the
sheath if it was adhered to it via scar tissue. The protocol was one
shot each month for three months, each shot $150. I was to expect no
improvement until several weeks after the 2nd shot.
The purpose was to
increase inflammation and trigger the healing process which had been
purportedly stalled. I could take a day or two off work (as it was
quite sore for a few days) but could bear weight as tolerated. Using
no ice or anti-inflammatories was important, to avoid suppressing the
inflammatory response, which was what I was paying for. And I could
get back to squatting the next week (slowly, of course).
As I would typically do
working sets in the 385-405 lb zone, I started post-op week one with
135 lb 3×5, post-op week two 225 lb 3×5, post-op week three 315 lb
3×5, then get one more workout before I got a shot and had to reset
again. During this entire time my heel was generally stiff and achy
and I limped around. I found no difference how I felt if squatted or
deadlifted, which was quite interesting. I could, however, feel much
much worse if I did isolated calf exercises.
About 4-5 months after
starting the shots, I was about 50-60% better. I probably should have
pushed into eccentric loading a bit more at that time. Every time I
did, however, I was so much more achy for several days I really
didn’t want to. After 8 months, I had not made any more
progression. I consulted with the doctor again and she suggested
either another shot or MRI for more information, so I got another
shot. The recovery from this one was quite miserable, for some
reason. For over a month I limped around work in constant pain and
was thinking I really needed to think about an MRI and maybe a
surgery.
In frustration, I
started to think of all the little things that might help me cope
with walking around all day at work, so added some heel inserts to
take a little tension off the tendon. My hormone doctor also
suggested anything that might help blood flow, and suggested perhaps
topical glyceryl trinitrate on the tendon could help. As could
extracorporeal shock wave therapy (ESWT) which is a non-invasive form
of treatment, that has been developed from ESWL (extracorporeal shock
wave lithotripsy).
When I looked into
evidence for use of ESWT for tendons, it seemed like it provided no
obvious benefit. I did have access to an ultrasound machine. Standard
physical therapy protocols for ultrasound are usually 8 minutes long.
This is because when billing the patient, at least 8 minutes must be
spent doing “something” to bill for a 15 min increment. I decided
to use 15 minutes of ultrasound 2x per week at the appropriate
settings. Ultrasound has been purported to have an effect on tissues,
though the exact mechanism is somewhat unclear in vivo. I did notice
the day after using it I felt a bit better, so I continued to do so
for next four weeks. I’m not sure if it was the effect of all the
little things I was doing or simply time, but about 7 weeks after the
4th injection I had days where I was hardly stiff, achy,
or limpy. I have been able to begin eccentric loading and
tolerating/progressing as I would have expected. I think by June I
should be close to normal, if things progress as expected.
A note to others:
tendon remodelling is a notoriously frustrating process. I would tell
my patients the parameters for loading (based on their pain and
tolerance during an exam) and to expect about 10% improvement a week,
and that it would take about three weeks to see ANY improvement. I
would have them do exercises twice a day, purposefully finding a load
that would increase their pain by about 2 points (on a 10-point
scale) for at least 5 minutes but not more than 20 minutes.
It is helpful (usually)
to have an objective viewpoint of your condition, and I could see a
patient once a week for 3 weeks to determine if they were trending
appropriately, correct their form and adjust their loading program,
then see them once every 2 or 3 weeks after that. So maybe 6 visits
over 8-12 weeks if things are going well. If you’re not improving
significantly after 3-4 weeks, its time to think of other options.
Other tendon conditions
which respond to this type therapy are the patellar tendon, elbow
extensor tendon (“tennis elbow”), and elbow flexor tendon
(“golfer’s elbow”).
References
Alfredson, H. Heavy-load eccentric calf muscle training for the
treatment of chronic Achilles Tendinosis. The American Journal of
Sports Medicine. 1998, Vol 26, No. 3
Auersperg, V. Extracorporeal shock wave therapy: an update.EFORT Open Rev. 2020
Oct; 5(10): 584–592.
How Defying One’s
Boss Led To A New Medical Discovery (forbes.com) Accessed 4/20/24
Hsu, C. Prolotherapy: a
narrative review of mechanisms, techniques, and protocols, and
evidence for common musculoskeletal conditions. Phys med rehab Clin N
Am 34 (2023), p 165-180.
Kohle,M. Foundational
Principles and Adaptation of the Healthy and Pathological Achilles
Tendon in Response to Resistance Exercise: A Narrative Review and
Clinical Implications. J. Clin Med. 2022, 11, 4722
Lorenz, David.
Eccentric exercise interventions for tendinopathies. Strength and
conditioning journal. 2010, vol 32, number 2.
Stania, M.
Extracorporeal Shock Wave Therapy for Achilles Tendinopathy. M.
Biomed Res Int. 2019 Dec 26:2019:3086910. doi:
10.1155/2019/3086910.eCollection 2019.
Treating tendinopathy
with Professor Håkan Alfredson by “BMJ talk medicine” podcast
(soundcloud.com)
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