Chronic Tendinopothy of the Achilles Tendon and Plantar Fascia

Pain on the back or bottom of the heel caused by a condition known as tendinopathy is a common problem among people who are trying to lead an active lifestyle. The Achilles tendon and the plantar fascia are tendon type tissues that each play a key role in maintaining balance while walking and standing and are commonly afflicted with this condition. The pain in these areas often emerges from overuse following repetitive strain or after a recent increase in activity. Most people who have heel pain from tendinopathy will experience relief with the use of stretching, supportive shoes, anti-inflammatory therapy and shoe inserts. However, if the condition is not addressed, the acute inflammatory process continues as the body attempts to repair the damaged tendon. Eventually, this healing process ceases as the tendon becomes riddled with scar tissue.

Chronic tendinopathy in these areas can severely impair your ability to function in your daily life. Often described as tendinosis or fasciosis, this recalcitrant condition may persist for more than 6 months and is not relieved with the use of anti-inflammatory medicine or corticosteroid injection. This chronic, degenerative process manifests as thickened fibrous tissue within the tendon or fascia. Blood flow decreases to the diseased area and the normal healing process is halted. If conservative options fail to alleviate the symptoms of chronic tendinopathy, novel therapy that involves restarting the healing process should be the next option considered. Since healing is a normal response to injury, restarting the healing process in chronic tendinopathy could involve either introducing a controlled injury to the fibrotic/scarred tissue or directly implanting the necessary growth factors. There are several therapies currently available for treating pain due to chronic tendinopathy.

New Approaches to Treating Chronic Tendinopathy

 TENEX FAST - Focused Aspiration of Scar Tissue

The TENEX FAST system provides a novel way of directly accessing the diseased portion of tendon, using ultrasonic energy to break the fibrous tissue within the Achilles tendon or plantar fascia. This minimally invasive approach uses a handheld device with a micro tip. Using ultrasound imaging as a guide, the handheld micro tip is brought to the area of injury through a small incision in the skin. With the use of a foot pedal, ultrasonic energy is emitted through the micro tip to emulsify the scarred portions of tendon. The micro tip is also equipped with a saline delivery system to flush and aspirate/remove the debrided fibrous tissue. This process has been termed phacoemulsification and essentially cleans the scar tissue in a focused manner, leaving behind healthy tendon. (1) Prior to the procedure, local anesthetic is injected near the affected area to control pain during the procedure.

For procedures involving the plantar fascia, one can bear weight on the affected limb with a CAM boot and cane for assistance for 2 weeks. For Achilles, a CAM boot and crutches for guarded weight bearing is used. After the procedure, the doctor will determine when transition out of the CAM boot to supportive shoe gear and careful return to normal activities is appropriate. Any discomfort experienced following the procedure can be controlled with pain medication as prescribed by the doctor.

 

Platelet-Rich Plasma Injection

Platelet Rich Plasma, or PRP, is an orthobiologic substance that is used to alleviate pain caused by chronic tendinopathy. As mentioned previously, the diseased portion of the tendon has decreased blood flow and is unable to heal. PRP functions by directly stimulating the healing process in this area through the use of growth factors and inflammatory molecules from the patient’s own body. Prior to the procedure, blood is drawn from the patient. It is then spun in a centrifuge to separate the platelet-rich plasma from the rest of the blood. (Because a centrifuge or spinning machine is used in this procedure, PRP is sometime commonly known as, “Blood Spinning”) The platelet rich plasma is then drawn out of the processed vial and injected into the affected area. This procedure has now directly implanted growth factors into the site of injury. These growth factors help recruit other cells from the body which are involved in healing of the injured soft tissue.

During the procedure, ultrasound imaging is used to visually inspect the tendon or fascia and find the specific region of injury. Once the area of injury is located local anesthetic is used to numb the area of interest and the PRP is injected. In order to stimulate the process of healing, many small injections will be peppered into the diseased tissue to introduce a form of micro trauma and encourage the body to recruit inflammatory cells. Doing this essentially restarts the healing process in the previously scarred tendon. Following the injection, anti-inflammatory medications and icing should be avoided in order to allow the inflammatory healing process to work. A short leg-walking CAM boot is worn following the injection. Avoid walking without the boot on the affected limb for 2 week.  After 2 weeks, patient can transition to supportive shoe gear.

 

Amniovo – Amniotic Membrane Injection

 Amniovo is a form of dehydrated human amniotic membrane and is another way to introduce growth factors to the site of injury in chronic tendinopathy. Although amniotic membrane tissue is known to possess healing potential, there would be risks involved with direct implantation of untreated, fresh amniotic membrane. In order to avert these risks, the amniotic membrane used in this process is taken from screened and tested donors, it is then purified using the PURION process. This purification process allows for the dehydrated amniotic membrane to be safely implanted to the affected site without the risk of disease transmission and allows for the graft to be stored for up to 5 years. Once purified, the product is in powder form and is suspended in saline solution to use as an injection. Through the direct implantation of growth factors, injection with Amniovo helps the tendon’s diseased tissue heal. In fact, in a study using dehydrated amniotic membrane injection compared to a control injection of local anesthetic and saline the amniotic membrane injection was shown to be more effective at relieving pain from chronic plantar fasciosis. (2)

Once again, ultrasound-imaging guidance is used to identify the diseased portion of tendon or fascia. An anesthetic injection is first used to numb the affected area and Amniovo is then injected.

Following the injection, a walking boot is used for 2 weeks in order to protect the involved site. Two weeks after the injection the patient can transition to supportive shoe gear.

In Conclusion

Chronic tendinopathy is an issue that plagues many people who are attempting to engage in an active lifestyle. Because the condition may not respond to anti-inflammatory therapies, many patients are frustrated, especially if they would like to avoid surgery. Novel therapies that combat this chronic, degenerative process have emerged that help restart the healing process in the diseased tissue. If you have had heel pain from chronic tendinopathy that has stopped you from leading the daily lifestyle you would like to, speak with your doctor to see which therapeutic option would best suit your needs and help you get back on your feet.

 

References

1) Barnes, D. Ultransonic Energy in Tendon Treatment. Operative Techniques in Orthopaedics. 2013

2) Zelen, C; Poka, A; Andrews, J. Prospective, Randomized, Blinded, Comparative Study of Injectable Micronized Dehydrated Amniotic/Chorionic Membrane Allograft for Plantar Fasciitis—A Feasibility Study. Foot and Ankle International. 2013

 

Healing yourself with Protein Rich Plasma

Platelet rich plasma (PRP) therapy is a cutting-edge non-surgical technique that is now available for use as an in-office procedure. Years ago, it was thought that platelets functioned solely to form blood clots — or, more specifically, to bind to each other at the sight of bleeding in order to form a “plug” to stop the flow of blood. Recent research has shown, however, that the platelet has a far greater role in the healing process than initially thought. When platelets aggregate at the sight of an injury, they not only form the plug to stem the bleeding but they also release growth factors. These growth factors, also known as cytokines, aid in the healing of injured tissues.

The Process: PRP therapy requires only a small amount of normal blood from the patient (approximately 20 cc’s). This blood sample is placed into a centrifuge in the office and is spun for approximately fifteen minutes. The final product is a highly concentrated platelet rich gel, which, when applied to injured tissue, accelerates the normal healing process.

On the day of the treatment, the patient is seated in the exam chair and blood is taken from his or her arm. Once the PRP gel is ready for implantation, the area being treated is injected with local anesthesia after which there is no further discomfort from the procedure.

To insure the accuracy of the placement of the platelet rich gel a diagnostic ultrasound is used. Then a needle attached to a syringe containing the gel is guided by the ultrasound into the areas of injury. After the procedure, a simple Band-Aid is applied. Because there is no surgical incision involved there is little or no post procedural pain.

The Science: When the PRP gel is applied to the area of injury, the platelets are activated to produce proteins capable of stimulating cellular growth, proliferation and cellular differentiation called growth factors. By concentrating the number of platelets found in normal blood by 10 times, the concentration of growth factors in the area is equally enhanced. This is significant in terms of the healing process because growth factors are responsible for attracting stem cells that will eventually become new tendon, bone or fascia.
The procedure is very safe. Since the blood is drawn and processed immediately in the same facility there is no chance of contamination or blood from another patient. Also since the injection consist of blood from the same patient begin treated there is no chance of allergy or drug reactions. Additionally, platelets have a natural antibiotic quality so there is very little chance of infection.

Use: In my practice, by far the most common ailment treated with PRP is the painful heel condition known as plantar fasciitis. However, I have also successfully treated tendonitis, partial tendon ruptures and inflammatory bone conditions.

PRP vs. Cortisone Injections

When PRP is compared to cortisone injections for inflammatory conditions there are many striking differences. Cortisone injections result in immediate pain relief. PRP injections do not act as quickly. PRP procedures take longer to deliver results because the growth factors take time to grow the new tissue. However, the platelets release the growth factors that attract the stem cells and then produce repaired “new” tissue. The cortisone reduces the inflammation immediately but actually causes tissue weakening and damage. So the choice between cortisone and PRP comes down to fast relieve with potential tissue damage or actual new and repaired tissue that takes longer to relieve pain.

This innovative and cutting-edge technique is just the beginning of the new branch of science known as “orthobiologics”. The day is fast approaching when medical science will be able to create new parts to cure the ailments and injuries that plague our bodies. “Protein Rich Plasma” is one of the modalities that are currently available to help the body accelerate the healing process and create new, repaired, healthy tissue.

PRP in the news:

The following articles on PRP are sited for your further reading on this subject:
http://articles.latimes.com/2008/oct/03/sports/sp-dodfyi3

http://www.nytimes.com/2009/02/17/sports/17blood.html?_r=1&emc=eta1

http://www.sportsgeezer.com/sportsgeezer/2009/02/simple-blood-treatment-helps-heal-most-sports-injuries.html

Heal Pain: What is it and how can can I relieve it?

Not a week passes by that while I am walking through the gym, I notice someone passing by who cannot put one of his or her heels on the floor.Some are women, some men, some thin and some heavy. As long as you walk, you are candidate for heel pain.

Every year, millions of Americans suffer from heel pain. By far, the majority of the cases of heel pain are caused by a condition known as plantar fasciitis (pronounced: fas-HEE-I-tis). This condition refers to the inflammation of the connective tissue that runs through the bottom of the foot from the heel bone to the front of the foot. This tissue is known as the plantar fascia. The fascia is most closely related to a tendon in appearance and texture, however, unlike a tendon there is no muscle attached to it. Due to the nature of this tissue, it is not very elastic and will get injured and begin to tear when exposed to excessive pressure. There are some factors that can make developing plantar fasciitis and heel pain more likely:

Aging. As we age, tissue breakdown becomes more prevalent. Accordingly, aging contributes to likelihood of damage to the plantar fascia.

  • Poor shoe gear. Shoes that have little or no support tend to place greater strain on the fascia.
  • Sports. Activity such as high impact aerobics, running and dancing can put a lot of pressure on the heel thereby causing pain.
  • Poor biomechanics. Persons with high arches or flat feet are more prone to get heel pain. People with flat feet apply a greater stretching force on the fascia. When they walk, they have a greater tendency to damage the tissue by over-stretching. People with high arches have very tight fascia.This results in poor absorption of shock and allows the fascia to become injured from strain.
  • Weight. There are many serious problems associated with being overweight. One of these problems is a strenuous challenge to the muscles, connective tissues and skeleton. In the heel, carrying extra weight makes the injuries that occur with poor biomechanics happen more often as well as more quickly. The excess weight also causes breakdown of the protective fat pad under the heel bone, which can result in direct injury to the heel bone and the fascia.
  • Occupation. People who have to stand at work for long hours on hard surfaces are also subject to heel injury.

There are usually classic symptoms associated with plantar fasciitis. Here is a list of what you might feel if you have this condition:

  • Sharp stabbing pain on the inside part of the bottom of the heel.
  • The pain is usually worst first thing in the morning or upon getting up after sitting for an extended period of time.
  • The pain may decrease after getting up, but the longer you are on your feet, the more the heel hurts.
  • The pain may diminish during exercise, but will increase soon after.

If you have this kind of heel pain, you are not alone. As I mentioned before, millions of people suffer from heel pain every year. However, if the pain doesn’t go away in a few days don’t ignore it. Although, most cases of heel pain are plantar fasciitis there is a possibility that it could be something else and even something more serious. Some of the other conditions that cause heel pain are:

  • A stress fracture of the heel bone.
  • A bone cyst or tumor in the heel bone.
  • A nerve entrapment behind the ankle, called Tarsal Tunnel syndrome.
  • Certain types of arthritis.
  • A partial or complete tear of the fascia.

Now that you know what it is, what can be a contributing cause, what it feels like and what else it might be, what can you do to help control the symptoms of plantar fasciitis?

  • First and foremost, is stretching. By stretching the back of the lower leg, you will relieve the tension on the heel and subsequently relieve the stress on the plantar fascia. The most important stretches are the typical runners wall stretch. These exercises should be done throughout the day; one set per hour is ideal.  Watch my YouTube video to see the stretches demonstrated.  http://YouTube.com/watch?v=_sDrvbd-Ppc
  • Night splints are devices that are worn to bed. They hold the foot and ankle in a position to prevent contracting of the muscle and tendon that you have been stretching all day.
  • Ice massage done one or two times a day for about 10 minutes. This can be done while sitting in a chair and rolling your arch and heel on a small bottle of frozen water.

The next phase of therapy consist of oral or inject able anti-inflammatory drugs. A physical therapy regimen may be utilized to reduce the stress and strain on the fascia as well as reduce the internal swelling. At this time, custom orthotics can be fashioned to relieve the pain from plantar fasciitis.Orthotics and continued stretching are the best insurance against having a recurrence of the heel pain.

After these treatments more than 90% of patients with heel pain will have minimal or no symptoms. If you are suffering from heel pain, stretch, ice, wear good supportive shoes, diet and see your podiatrist for a complete evaluation.

What about the 10% of those who are not pain free?

See my next article on the treatment of resistant heel pain. In this article I will review PRP (Platelet Rich Plasma) injections, ESWT (Extracorporeal Shockwave Therapy), and surgery for heel pain.

Get on your feet!

As both a healthcare provider and a lifetime participant in a variety of fitness activities, I consider myself uniquely situated to be able comment on physical fitness and the lack thereof. As an avid exerciser, I am able to observe people in their role as exerciser, and as a podiatrist, I am able to see the result of poor training technique, over use and injury as a result of bad luck. On a daily basis, I listen to the stories of sports and fitness participants on all levels–those who have run a dozen marathons virtually unscathed, climbers who have scaled Mount Everest, would-be athletes, who, at forty, have just started yoga, pole dancing, or a walking program, and so on. From the avid life long sports participant to the middle-aged convert, all of these people have one thing in common–they are engaged in a healthy lifestyle. As I urged you in my last article, get off the couch and get moving.

Here is a list taken from the Center for disease Control’s web site outlining the benefits of regular exercise:

The Health Benefits of Physical Activity—Major Research Findings

  • Regular physical activity reduces the risk of many adverse health outcomes.
  • Some physical activity is better than none.
  • For most health outcomes, additional benefits occur as the amount of physical activity increases through higher intensity, greater frequency, and/or longer duration.
  • Most health benefits occur with at least 150 minutes a week of moderate-intensity physical activity, such as brisk walking. Additional benefits occur with more physical activity.
  • Both aerobic (endurance) and muscle-strengthening (resistance) physical activity are beneficial.
  • Health benefits occur for children and adolescents, young and middle-aged adults, older adults, and those in every studied racial and ethnic group.
  • The health benefits of physical activity occur for people with disabilities.
  • The benefits of physical activity far outweigh the possibility of adverse outcomes.

http://www.health.gov/paguidelines/guidelines/chapter2.aspx

The following story, taken from the annals of my daily contact with people, drives home an important point about accomplishing anything in life: if you are going to do something, do it correctly.

The American Diabetes Association recommends an annual visit to the podiatrist for all diabetics, even for those without risk factors. If patients have risk factors, the frequency of regular foot exams increases. Risk factors include absent pulses in the feet, loss of sensation in the feet or prior amputation of part of the foot. Yesterday, a diabetic male patient in his late fifties came in for his annual visit. The following is an account of our conversation:

I ask, “So how have your blood sugars been?” The patient responds, “not so good Doc.” Then I say, “Looks like you have gained some weight this year.” The patient responds, “Yes Doc, I gained about 10 pounds this year.” I then inquire, “Have you been getting any exercise?” The patient says with enthusiasm, “Oh yes Doc, I have been walking.” At this point, I now see some hope…at least he has started to participate in some cardiovascular activity. I respond: “that is great! Tell me about your walking program. How far are you walking? And how many days a week are you walking?” He then looks at me with some confusion and says, “No, I mean I am just walking, you know, from the train stop to my office and then, during the day, I walk in the office like to the copy machine or the men’s room.” I am not even sure what happened next, I think I was thrown into a state of consternation.

As a podiatrist, I can say that in normal walking you strike the ground with your heel and then load the front of your feet with 1.5 times your weight. This means that for every pound you gain, you are putting 1.5 pounds on these areas of the feet. This will result in trauma to the skin and the skeleton, as well as to the tendons in your foot and leg. Think about the other body components, the heart, the lungs, the blood circulation and burden of carrying additional weight.

Sometimes people exercise for menial goals, like to lose the newly noted love handle or tighten up that rear. But, you must realize that exercising is for your life. Please recognize, as I said in my prior article, that even if your motivation for doing the exercise is for your kids, your wife, your parents, it always comes down to the fact that it is for you—your life. In my last article I asked you to set a goal, now I am asking that, in addition, you follow through on that goal properly and appropriately–don’t kid yourself.

A 160-pound person running at 5 miles an hour will burn 307 calories, that same person will burn 38 calories reading for an hour. Reading, sewing, knitting even moving your foot on the gas pedal is to some degree exercising–but that is not sufficient. The United States Center for Disease Control recommends at least 30 minutes of exercise 5 or more days a week. Cardio exercise is not walking around the office, stretching is not bending to pick up the newspaper on your doormat; real results need real exercise. Read books or magazines about what you want to get involved in. Ask an expert if you have no clue. Ask your doctor, a trainer at the gym, a rock-climbing instructor, a ski pro, etc.

A study published in the New England Journal of Medicine in 2004 examined over 100,000 women and found that excess weight and lack of physical activity accounted for 31 percent of premature deaths. Another study conducted in Finland in 2004, which studied also nearly 16,000 men aged 30 to 59 over a 20-year period: Found that men who were engaged in a physically active lifestyle were 21% less likely to die of any cause during the course of the study. This increase in deaths was found to be primarily from heart attacks and strokes, but also from cancer. With this in mind, don’t you want to see your children or grandchildren a little longer? Don’t you want to experience quality life a little longer? I am sure the answer is YES. Get going, get started, it is time to move. Please, Don’t kid yourself.

Connecting Your Mind and Muscles

I have been a podiatrist for the past 27 years, I have been a health nut, exercise enthusiast and “gym rat” even longer. Over the years I have seen a variety of strange exercise techniques as well as even stranger cardio/exercise procedures and ever more outlandish locker room activities. Having spent five to six days a week training in the gym all these years, there are plenty of yesterdays in the gym. Being a healthcare provider treating the foot and ankle for nearly three decades there are plenty of times I get to see the resulting insult and injury for some of those behaviors I have observed at the gym the day before.

However, not all is lost to my observations of those aberrant quirks that result in detrimental outcomes. I have also seen a lot of excellent technique and beneficial behaviors and have incorporated these to make my workouts and I dare say, my life, better. Let’s face the facts—exercise and keeping yourself in shape is far more advantageous to one’s overall well being then the few temporary set backs to the skeleton or skin that all athletes suffer from time to time. Even with decades of experience, I still subscribe to the “injury of the month club”. However, over time I strive to correct, improve and attempt to perfect my exercises, my treatment of patients and my life. I would say that much of this improvement I owe to that microcosm I choose to spend so much time in “the gym”.

The United States Department of Health and Human Services recommends 60 minutes of exercise daily just to maintain your current weight.

For the purposes of this article my message is not, see you at the gym tomorrow, however the message for today is get started improving your life. Not all exercise is done in the gym. I am not suggesting that my type of exercise is what everyone should do, nor is it the only way to stay in shape.Millions of years of evolution did not produce our arms and legs, heart and lungs to sit at our desk all day and our couches all night. Dependant on you age current health and what you enjoy, raking leaves, taking a brisk walk, playing volleyball or basketball. It is time to start using your body for more than using the Gluteus muscle as a cushion.

Why should you start exercising? Possibly, for others–your children, teammates, co-workers. Don’t let them down. Definitely, for yourself. You may feel better with an improved self-image, more energy, or having powers and abilities far beyond the average couch potato. You can’t let yourself down.

How do you start? From many conversations at the gym the reason most people tell me they are staying in shape is to avoid the relative poor health of generations gone before. Interestingly, that same theme is repeated in my office when I hear, “well I know it is not bad now, but I don’t want to wind up like Grandma Mary.” So maybe you don’t want that early heart attack, the hip replacement or type 2 diabetes. Think about how painful and depressing developing one or all of these ailments would be. Develop the mindset that each and every time you are exercising in some way, you are literally pushing back that illness. Of course I am not ignorant, not everyone will succeed at staving off the family genetic predisposition to illness. However, not everyone goes into marriage anticipating a divorce.

Set a goal. This is important for your exercising, as well, as all the other aspects of your life. Some of the motivational experts will tell you that you have to write it down and keep looking at it. I think they are correct.However, I believe that once you write it and look at it and you can then throw it out. (The paper that is) This is because once your hand has written it, then it is true and therefore you have to follow through. Maybe you want to get below 200 pounds or maybe ever 300 pounds. Maybe you want to run a marathon or just walk around the block in less than 15 minutes. Maybe you want to bench press 315, 225 or just the bar. Maybe you want to dance all night without waking up the next day with your legs killing you. Or maybe you’re like me and want to think that you will still be doing a half hour of cardio, a half hour of weight training and abs and stretching when I am 95.

It is now time to get off the couch and move. Whatever goal you have set, when you reach it you'll feel great. As a matter of fact, once you reach your first goal you will feel so good you should have no problem setting your next objective. It is your mind, your body, and your life...make the most of it.