Articles


My Tangle With Tendinopathy

by Rob Brouillard DPT | May 08, 2024

foot tendon anatomy drawing

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 3x5, post-op week two 225 lb 3x5, post-op week three 315 lb 3x5, 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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