Achilles Pain. Time to Take Action!

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I’ve had periodic issues with my left Achilles tendon. I’ve never had trouble with my right Achilles until just lately. I felt a bit of soreness one morning and found some swelling. I knew it probably wouldn’t “work itself out” (I sort of hate when someone says that about something. Nothing “works itself out.” Someone has to put in work in order to see progress.) The upside to having had this problem before is that I know how to address it now.

I believe my trouble may have started because of the long trail run/hike I did a couple of weekends ago in Telluride. It was about 12 miles which was a sizable jump from my prior long run of 7 miles. (Sometimes I’m not smart.)

I have attacked the injury with a fairly conventional strategy of slow and controlled heel raises. Here’s what it looks like:

I’m doing these exercises frequently throughout the day. If I can hit 15 reps then I add weight. Fifteen reps isn’t a magic number by the way. Most importantly I work to a high level of exertion, pretty much to failure.

I’ve run several times since feeling pain and doing the calf raises and I feel fine. That’s a good sign. I probably don’t need to take time off from running.

This exercise is boring and I hate doing it. (Sounds like what a lot of people say about going to the gym.) I have shown a propensity for weakness in my Achilles tendons in the past though. This is exactly the type of thing I need to do and I should be doing continually. It’s easy to skip this stuff because I don’t enjoy it. My body doesn’t  though even though there are potential negative consequences to this course of non-action.

There are lots of things in life like that.

Achilles Tendonitis Progress

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My Achilles pain was getting better and then it flared up again recently and it has stayed flared for a while. This has been an ugly aggravation as it was a serious regression. Now, I’m very happy to report that my Achilles tendon irritation seems to be fading away. I’ve done three short-distance run/walks with no pain. (Will it stay gone is the real question.) What has helped?

Time off

Initially I thought that simply changing the way I ran would allow me to side-step whatever healing process that needed to take place. I revisited several technique changes that helped me overcome a past bout of Achilles pain. I discovered that there was no magic fix. Minding my technique is a good idea but it seems my tissues still needed time to heal.

Heel lift

I put a 1/4 inch heel lift in my shoe. The idea is to give a little bit of slack to the sore tendon.

To this point, I made sure not to do much in the way of stretching the tendon. It’s often a mistake to think that if it’s sore, it must need stretching. In fact, the damage to the Achilles may have been brought on by it’s being stretched too much and/or too fast.

Eccentric strength work

I’m continuing the work I wrote about in the last blog post. Runner’sConnect.net has a comprehensive guide to both Achilles pain rehab and prevention strategies. I won’t rehash it here.

Extensor hallucis brevis work

I think this has been a BIG ONE. I believe that part of my problem stems from my inability to adequately anchor to the ground the distal end of my first metatarsal, aka the ball of my big toe. How might that affect my Achilles tendon?

Too much of this may over-stress the Achilles and cause pain.

Too much of this may over-stress the Achilles and cause pain.

If I can’t secure that first met head to the ground then I have a weak foot tripod as the Gait Guys have described it.That means that my foot might pronate in an uncontrolled way which can result in something like the image to the right. Too much of that done too often and/or too fast could over-stress the Achilles causing damage and pain. To form a solid foot tripod, I need to be able to secure the center of my calcaneus (heel bone), first metatarsal head (ball of the big toe) and the fifth metatarsal head (ball of the little toe.)

(To be clear, I can’t say this is The Cause for anyone else’s Achilles problems. Someone else may be able to run with lots of pronation and feel fine.)

How did I know I had difficulty getting that met head to the ground? I’ve been videoed running and I could see this extended pronation occurring. I could feel it as I tried doing the exercise in the following video. This gets into what seems like some real minutiae. For me, it seems pretty important. Also, I don’t believe this movement is trained in the eccentric strength protocol I mentioned above.

Metronome running

I’ve read several discussions (here, herehere) on running cadence and loading rate as it pertains to injury risk. Essentially, by using a quicker cadence we should load the tissues of the foot for less time per foot fall thus resulting in less stress to those tissues. That’s exactly something I need.

I went back to using a metronome when I run so that I can make sure to keep a quick pace. I set the metronome from 170 to 180 bpm and matched my cadence to the beat. It’s definitely a quicker cadence than what I’m used to. Seems I’ve backslid some on minding my cadence. Going forward, I think it will be a good idea to periodically run with a metronome to ensure that I’m staying quick on my feet.

 

More Achilles Tendon-itis/-osis/-opathy (or Whatever It Is)

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About three weeks ago I went for a run in the snow. Part way through I felt some irritation in my left Achilles tendon. Like anyone who loves/needs to exercise, I kept running and I tried to convince myself that it wasn’t too bad, that it would probably go away soon or maybe if I changed my stride slightly it would resolve during the run.

I was wrong! I really irritated the thing and had to walk about a mile. This was the latest flare-up of a years-long lingering issue. (I’ve discussed the Achilles here and here, as well as left heel pain/plantar fasciitis hereherehere, here, here and probably in some other places… You’d think for someone who’s considered this issue so much that I wouldn’t have it anymore.)

Prior to this Achilles flare-up, I’d had some of some old familiar heel pain. It wasn’t debilitating but it was a signal that something wasn’t as it should be. Again, I ignored it to a large degree and figured it would resolve. I should’ve paid closer attention to it. Essentially, it wasn’t a problem until it was a problem. Time to get back to work on this thing.

Tendon injury: A complex issue

Why do we get injured? How do our tissues (like tendons) become damaged? If we administer the right amount of stress and then recover we get a positive adaptation–we get stronger. In contrast, if we administer too much stress and we don’t recover then we get some type of injury. Thus too much stress delivered too often and/or too fast has been my problem. I need to increase my tissue tolerance to the forces of running.

A recent article from Alex Hutchinson is titled Pro Tips on Treating Tendon Injuries. This article covers a debate among members of the Canadian Association of Sports and Exercise Medicine in Ottawa. Several top sports physicians and therapists were asked: Which therapy should the squash player try next? (I’m not a squash player but I have the injury they discussed.) If you’re dealing with this issue it’s definitely worth a read. It discusses several methods: eccentric strengthening, nitroglycerin patch, dry needling, cortisone, and platelet-rich plasma.

There wasn’t 100% agreement on anything much, but Hutchinson’s concluding statement was this (emphasis is mine):

“So what should the poor squash player do? In the question period following the debate, most participants conceded that strengthening exercises are the path to long-term health. Depending on the specifics of your tendon injury, other techniques may provide relief to allow you to exercise, but they’re not permanent cures.”

Cures I like. I have no interest in simply treating symptoms. Thus I decided it was time to implement something with which I’d been familiar but which I knew wouldn’t be very exciting at all: the eccentric strength protocol.

Eccentric strengthening

First, what does “eccentric” mean?An eccentric contraction is one in which the muscle is contracted but it’s also lengthening. Think of doing a bicep curl. You know the part where you yield to gravity and lower the weight? That’s the eccentric portion of the movement. (In contrast, the concentric portion is where you overcome gravity and bring up the weight.) For this particular protocol, we want to fight against the lowering action and lower very slowly.

I found a very thorough resource for this project from Jeff Gaudette at RunnersConnect.net. It’s titled The Ultimate Runner’s Guide to Achilles Tendon Injuries: The Scientific Signs, Symptoms, and Research Backed Treatment Options for Achilles Tendonitis and Insertional Achilles Tendinopathy. (The title of this thing just screams ACTION!! doesn’t it?) You can download both the Injury Treatment PDF and the Injury Prevention PDF. As the title suggests, this is a thoroughly researched guide to dealing with tendon injuries. I appreciate very much that there is both a treatment and prevention strategy. I won’t go into the whole thing but here are the basics:

The strength protocol consists of two exercises: a straight-kneed and a bent-kneed
eccentric heel drop. The protocol calls for three sets of fifteen heel drops, both bent- kneed and straight-kneed, twice a day for twelve weeks.

Standing on a step with your ankles plantarflexed (at the top of a “calf raise”), shift all of
your weight onto the injured leg. Slowly use your calf muscles to lower your body down,
dropping your heel beneath your forefoot. Use your uninjured leg to return to the “up”
position. Do not use the injured side to get back to the “up” position! The exercise is
designed to cause some pain, and you are encouraged to continue doing it even with
moderate discomfort. You should stop if the pain is excruciating, however.

Once you are able to do the heel drops without any pain, progressively add weight using a backpack. If you are unlucky enough to have Achilles tendon problems on both sides,
use a step to help you get back to the “up” position, using your quads instead of your
calves to return up.

The eccentric exercises are thought to selectively damage the Achilles tendon, stripping
away the misaligned tendon fibers and allowing the body to lay down new fibers that
are closer in alignment to the healthy collagen in the tendon. This is why moderate pain
during the exercises is a good thing, and why adding weight over time is necessary to
progressively strengthen the tendon.

You do these exercises for 3 sets of 15 reps, twice daily. There are photos showing these exercises including a modification if you have what’s known as insertional Achilles tendonitis. Again, read the whole thing if you want the full rundown of this protocol.

More thoughts

Part of why I haven’t done this in the past is that it is slow and tedious! Three sets of 15 slow reps makes time crawl like some sort of crippled tortoise. It ain’t fun! Plus I’ve never cared much for doing calf work. That said, I need to fix this problem. This process seems to be the best way to go about it, so I’m on board.

Something else I realize is that if I’m prone to this injury and I want to avoid it then I need to do the preventive work. That means setting aside time throughout the week and during my workouts to do some of this stuff.

I’ve been doing this work for about the past three weeks and I am getting better. I’ve done a couple of short run/walks and I’m not in the clear just yet. The only option I see is to continue doing what I’m doing.

Update

I just went on a run of a little over two miles and the Achilles feels fantastic. No pain! Felt like I could’ve run all day–which would’ve been stupid of me. This protocol is working for me right now.

Activity is Better Than Rest for Overcoming Lingering Pain

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I’m glad to see Outside Magazine delivering a message that may be very useful to anyone suffering from pain. (This is from 2009, but I just saw it.) The article mirrors my recent experience with my ACL rehabilitationThe Real Heal: Overcoming Athletic Pain says two things essentially:

  1. Rest usually doesn’t cure what hurts us. (In fact, too much rest makes us deconditioned and contributes bad feelings in general.)
  2. Moving and using our sore parts–confronting the pain–is essential to getting rid of pain.

The writer discusses his journey following a bike crash which hurt his knee (an acute injury). He rested and took pain medicine. He states (emphasis is mine):

“It turns out my belly-up approach was dated. New research is proving that the best way to treat nagging pain is to eschew pampering in favor of tough love. Doctors at the University of Pittsburgh are doing ongoing research showing that stretching irritated tendons actually reduces inflammation. And the principle extends beyond rickety wiring. Every expert I spoke with told me variations of the same thing: ‘Rest and ibuprofen cure few injuries,‘ said Dr. Jeanne Doperak, a sports-medicine physician at the University of Pittsburgh. ‘During rest you’re in a non-healing zone,‘ offered Dr. Phelps Kip, an orthopedic surgeon and U.S. Ski Team physician. ‘The body was designed to move.'”

Pain is very much a psychological thing. I can relate to this:

“And it just so happens that tendinopathy chronic tendinitis is the most diabolical of recurring injuries. Give me a broken foot over tendon trouble any day when something snaps, at least you know what you’re in for. My injury dragged on into winter, deep-sixing my mood. This is not uncommon: The link between pain and depression is so well established that sports psychologists use a tool called a Profile of Mood States to monitor injured athletes. (This is a graph evaluating tension, depression, anger, vigor, fatigue, and confusion. People in pain score extremely high in every category except for vigor.) I was five years removed from being a college athlete and I was Long John Silvering it up stairs at work. Strange questions crept into my head: Could I consider gardening exercise?”

I like the overall message of the article but I don’t agree with all the information:

  • The writer says, “… or imbalances in the body’s kinetic chain of movement (a weak core can cause lower-back pain).”

Though this is a popular concept, there is significant evidence that “core strength” (which can be defined and measured in a multitude of ways) has nearly nothing to do with back pain.

  • For runner’s knee, the writer suggests this: “Lie sideways on a table, legs straight, and slowly raise and lower the upper leg ten times. Do three sets. Easy? Ask your PT for a light ankle weight.”

I think this might be part of an effective strategy to address runner’s knee (if the problem is rooted in the hip which it often is; however it could be rooted in poor control of the foot and ankle), but there are several dots that I think need connecting between this exercise and full-on running. This exercise is very different from running in which the foot impacts the ground and the runner must control motion at the foot, ankle, knee and hip. If this is the only exercise given to a runner’s knee patient then I’m skeptical that the runner will fully overcome the issue.

  • A caption under a photo reads, “Preventive Measures: Recovering from a nagging injury? Next time you go for a run or a ride, try taking ibuprofen beforehand. As long as you’re cleared for activity by your doctor, inhibiting swelling prior to a workout can dramatically reduce post-exercise inflammation and pain.”

This is an interesting idea but I have strong reservations. Pain is a signal that should be respected. Even though pain doesn’t equal injury it’s still a message from our brain that there is a perceived threat that needs to be addressed. The pain could be signaling a threat related to poor movement control and tissue stress is leading toward injury. By taking a pain-blocking drug, we might simply be turning down that signal as we continue with what may turn into an acute injury. I would compare this to driving a car with a damaged muffler that needs replacing and instead of replacing the muffler, we turn up the stereo loud: No noise!!–but have we fixed the problem?

On the other hand, I understand that even if the movement problem is addressed, we may still feel pain. Taking a drug may help the brain experience the new, better movement in a painless way which might help break the chronic pain cycle. I’m curious to what degree this has been method has been investigated.

For me, as a personal trainer, I would never suggest someone take a drug and just keep going. Rather, I would speak with the person’s PT. If he or she OKs it, I would then advise someone to move and work below the pain threshold or at a very manageable level of pain.

Pain, the Brain and ACL Recovery

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A few weeks ago I had a very interesting experience regarding my ACL rehabilitation. It’s very similar to an experience I had with Achilles tendon and heel pain. Here it is.

A perceived setback

I had ACL reconstruction on May 1, 2014. I have been very aggressive with my rehabilitation and I felt it was going very well. My PT and I agreed on a strategy and he approved of the process in general. I knew that sitting and resting was not the right way to go if I wanted to regain full function. For people like me, laziness wasn’t a problem; an overly aggressive approach might be though.

I knew that I could be in trouble if I did too much work too fast and stressed the knee too much. I worried that I’d drifted into this territory when at almost nine months I experienced more pain than I expected. I had a final appointment with my surgeon and she expressed some concern at my symptoms. We agreed that I should back off my activity and rest a bit. Seems perhaps I had reached the point of “too much of a good thing.”

I backed off lifting, running a cycling. I didn’t stop my activity completely but I cut it back significantly. After a couple of weeks I realized the knee wasn’t feeling much better. I continued to experience frequent pain; not debilitating but somewhat worrisome. I decided a visit to the PT was in order. I wanted to get some guidance and make sure I hadn’t damaged the graft.

The long and the short of the visit was this: The graft and my knee were fine. I needed more strength in the leg and around the knee. I needed to do more work, not less! Eureka! (My previous PT had moved on to another position and I had to meet with a new one. Unfortunately, the “bedside manner” of this PT left much to be desired. Right off the bat she was rude, dismissive and she interrupted my answers to her questions. I became very frustrated and it was work to keep my yapper shut and listen to what I needed to. Fortunately I got the information I needed.)

From here, I was ready to rock ‘n’ roll.

Goodbye fear. Hello confidence!

My experience was a very clear experience of what modern pain science has been finding recently. Here are some important points:

1) Pain doesn’t equal injury: In Reconceptualising Pain According to Modern Pain Science, neuroscience researcher Dr. Lorimer Moseley has made several points about pain. Two are pertinent here:

  • pain does not provide a measure of the state of the tissues
  • The relationship between pain and the state of the tissues becomes weaker as pain persists.

Yes I had an injured knee and yes I had surgery in which part of my patellar tendon was cut out in order to make a new ACL. This was all very disruptive to parts of the knee and was clearly part of the pain I was feeling. It takes about six weeks for the graft to heal. The reconstructed ACL is pretty much healed at six months which would’ve been October for me. In other words, my knee was/is healed and any pain wasn’t from tissue damage.

2) Fear is a significant obstacle that must be addressed: Fear is a powerful part of our pain. Overcoming that fear is major part of a successful rehab and return to activity. The pain in my knee caused me to worry that I’d re-injured it and it led me to avoid a lot of activity that I enjoyed. This condition is known as fear-avoidance. The International Association for the Study of Pain (IASP) describes fear-avoidance this way:

Psychological factors play a key role in the development of chronic musculoskeletal pain, in particular dysfunctional beliefs about pain and fear of pain. Fear of pain leads to avoidance of activities (physical, social, and professional) that patients associate with the occurrence or exacerbation of pain, even after they may have physically recovered. Whereas this response is adaptive in the acute phase—rest promotes recovery—it leads to disability and distress when avoidance behavior is continued after the injury has healed.

"Fear-avoidance model" by LittleT889 - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Fear-avoidance_model.jpg#mediaviewer/File:Fear-avoidance_model.jpg

“Fear-avoidance model” by LittleT889 – Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Fear-avoidance_model.jpg#mediaviewer/File:Fear-avoidance_model.jpg

When I learned that my parts were solid and strong and that I wasn’t broken, I felt the fear drain away like water down a toilet. I was a happy dude!

Another of Moseley’s points is important here: that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

Big words. What does that statement mean? I’ll let Moseley explain (emphasis is mine):

First, there are other central nervous system outputs that occur when tissue is perceived to be under threat, and second, that it is the implicit perception of threat that determines the outputs, not the state of the tissues, nor the actual threat to the tissues.

In even simpler terms, we may feel pain absent any damage but we feel pain when our brain perceives a threat–even when there is no threat. I compare this to a car alarm that is set off by the wind. There’s no break-in occurring yet the alarm signal is going off due to the alarm sensing a threat.

3) Patient education is vital: Very interestingly, an effective strategy in treating chronic pain is patient education. This strategy of patient education is supported in several studies that are discussed in a review in the Archives of Physical Medicine and Rehabilitation, and it’s further discussed in an article titled Can Pain Neuroscience Education Improve Endogenous Pain Inhibition? Literally, knowledge of pain processes can reduce pain. (Pain is weird!) I believe that my experience supports this phenomena.

(To be clear, it’s not that I received education on how pain works. I received the message that my knee was solid, not injured and that it could be worked very hard.)

Keep this in mind.

Dr. Moseley discusses pain education in Pain really is in the mind, but not in the way that you think. I like what he says here:

“The idea that an inaccurate understanding of chronic pain increases chronic pain begs the question – what happens if we correct that inaccurate piece of knowledge?

We’ve been researching the answer to this for over a decade, and here’s some of what we’ve found:

(i) Pain and disability reduce, not by much and not very quickly but they do;

(ii) Activity-based treatments have better effects;

(iii) Flare-ups reduce in their frequency and magnitude;

(iv) Long-term outcomes of activity-based treatments are vast improvements.”

Most of us outside the medical community probably still equate pain to damage. Many inside the medical community still think that way too. (Blame Rene Descartes.) We now know better. Rather than address pain from a strictly biomechanical approach, therapists would be well advised to study and adopt what’s known as the biopsychosocial model for pain. This model is explained very well here and discussed in-depth here. We patients will be well armed in a fight against pain if we understand this model too.

 

ACL Rehab Update and the Latest Workout

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The last post I sent out was sort of screwed up. Something was wrong with the code. Here’s the new and improved version.

Thursday was a full week since my ACL reconstruction and it was the day of my first PT appointment. According to the PT, I’m weeks ahead of schedule in terms of strength, mobility and gait. This was fantastic news and I’m completely convinced that my pre-surgery workout routine was the key.

The current thinking on ACL reconstruction and recovery is to engage in what’s known as prehabilitation (as opposed to rehabilitation) prior to surgery. Surgery is a type of controlled injury. Though the overall goal of surgery is to improve function and “fix” an injury, the immediate outcome of surgery is pain, poor movement, weakness and maybe instability. The aim in prehab is to make the involved area as mobile, strong and highly functional as possible so as to minimize the impact of surgery.

My prehab consisted of lots of squats and single-leg work, deadlifts, walking, and bicycling as well as various stretches and plenty of upper body and trunk/core work. Most of my work consisted of sagittal plane (front/back) movement. This was the most stable plane of movement available to me. I also did some frontal plane (side-to-side) work but only a little work in the transverse (rotational/twisting) plane. A torn ACL typically results from way too much twisting so I was very careful not to twist and I used anti-rotation exercises in which I worked to resist forces trying to twist me.

On Friday I did my first workout.  Here’s what I did. Take note of the single-leg work. This was a big part of my prehab and will be a huge part of my rehab.

Super set 1

    • Barbell press: 65 lbs. x 5 reps – 75 lbs. x 5 reps – 85 lbs. x 5 reps – 95 lbs. x 5 reps – 105 lbs. x 5 reps – 115 lbs. x 5 reps – 120 lbs. x 5 reps – 120 lbs. x 5 reps – 70 lbs. x 12 reps
      • That last set was a back-off set. I’ll be employing back-off sets with various exercises and I’ll probably discuss back-off sets later.
    • 1-leg exercises: Watch the video for an explanation
    • Toe raises (aka heel raises or calf raises): 2-foot x 30 reps – 1-foot x 10 reps.  I alternated this pattern throughout the super set. I only used my body weight.

Super set 2

  • Leg lifts: 12 reps – 10 reps – 10 reps
    • Haven’t done these in forever.
    • I got sore and tired in the abdomen very quickly!
    • Might be sore tomorrow
  • Band walks:
    • Went to exertion in the hip abductors
    • I was very careful to keep my right knee from caving in, which is an example of working to avoid transverse plane movement as I mentioned above.

    Finally, I was able to just turn the cranks on a recumbent bike. I couldn’t generate much force with my leg but still, to get a full revolution was good news. I figure I’ll be on a real bike in maybe a week.

What Goes Into A Successful ACL Reconstruction? An Interview With Kurt Spindler, MD

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“I really want to know what predicts ACL reconstruction failure or success so that we can improve our outcomes.” – Dr. Kurt Spindler, MD – Cleveland Clinc

In the course of scouring the Internet for any and all information on ACL injuries and rehabilitation, I came across a research summary titled Predictors of successful ACL reconstruction found. The research comes from the Multicenter Orthopaedics Outcomes Network (MOON), led by Cleveland Clinic’s Kurt Spindler, M.D.  Dr. Spindler is the Vice Chairman of Research in the Orthopaedic & Rheumatologic Institute, the Director of Orthopaedic Clinical Outcomes, and the Academic Director of Cleveland Clinic Sports Health. MOON consists of 17 surgeons from seven institutions. The researchers wanted to establish a “gold standard” for ACL reconstruction and rehabilitation. A related project is the Multi-center ACL Revision Study (MARS). I got to speak with Dr. Spindler recently. He gave me a lot of good information on several topics. After speaking with him I feel very well informed on what to know and what to ask as I start to navigate my way to a new ACL.

What are the big takeaways from the research?

  • Choose the correct type of graft. (An allograft comes from a cadaver. An autograft comes from you, either as part of the patellar tendon or hamstring.) There are advantages and disadvantages to both. Age and activity level are important factors. For teenagers and twenty-somethings, the autograft is best. I told him that I’m highly active and I intend to return full-bore to my activities. He said the autograft (either hamstring or patellar tendon) is right for me.
  • First-time ACL reconstructions perform much better than second reconstructions. Be patient. Do the rehab correctly and don’t rupture the repair!
  • Pick a skilled surgeon, one who does a lot of reconstructions and does them frequently.
  • Do the rehab! (I intend to make my rehab a religion.)

To what degree should I stay off my feet and avoid activity? Is it safe to do any type of activity? If so, what?

  • Pain should be my guide. If it hurts then stop.
  • I can exercise to whatever degree I’m able, so long as it’s gentle work and pain free.
  • I can use an exercise bike, paddle around in a pool, do squats (unweighted obviously) and any other sort of work that I can tolerate.
  • Avoid fast movements and twisting.

In speaking with surgeons, what questions should I ask?

  • How many repairs have you done?
  • How many repairs per year do you do?
  • On whom have you done them? Athletes? Kids? Sedentary people?
  • How involved are you in the rehab program? Will I just receive a handout of exercises to do or will you monitor my progress and adjust the program as necessary?

Is there an ideal rehab protocol?

Dr. Spindler said there wasn’t a strict protocol that’s best. Every injury and every individual will progress differently and rehab must be adjusted accordingly. He directed me to the evidence-based MOON rehab guidelines.

How soon should surgery follow an ACL tear? 

  • The knee should have good ROM.
  • Swelling should be down.
  • Good muscle function should be present.
  • The patient should be able to walk.
  • A long wait increases risk of further injury.

What should I know about miniscus damage? In the case of a damaged miniscus, how much can be salvaged?

  • Tissue with good blood flow can be salvaged.
  • Overly damaged tissue without blood flow should be excised.

What should I know about ACL repair using a bioenhananced scaffold technique?

At this time, there doesn’t appear to be any advantage to using this experimental technique.

He told me I had several favorable factors on my side:

  • I’m athletic.
  • I don’t smoke.
  • I have a good BMI.

One variable that I can’t control is the amount of damage to the knee. My MRI said I have a partial tear and some damage to the MCL. I’ll learn more on Thursday when I meet with an orthopedist. Thank you to Dr. Spindler and the Cleveland Clinic for the interview. This has been a huge help to me and I hope it helps someone else with a bad knee.

The Final Victory Against My Heel Pain Part II: The Brain and Pain

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This piece about my heel pain was in the works prior to my ACL mishap. It was great to banish my heel pain! I’m still happy about it! Now I just have to overcome this latest speed bump and all will be well.

In Part I of this post I discussed my consultations with coach Mike Terborg and therapist Nick Studholme. We were trying to figure out how to resolve some very persistent heel/Achilles tendon pain that had been with me for several years. Their work was biomechanical in nature. They helped me to move better, run better and unload the sensitive tissues.

Here in Part II I want to discuss another important component to pain management, one that has less to do with biomechanics and everything to do with how we think about pain. Z-Health is where I first learned about these concepts. I drifted away from Z-Health a bit but I’ve returned to my learning about the realities of pain.

Key points

  • Pain is in the brain.
  • It’s a blend of nociceptive (danger) signals, attitudes, beliefs, past experiences, knowledge, social context, sensory cues.
  • It doesn’t equal tissue damage–particularly in chronic pain cases like mine.
  • Pain is a response to a perceived threat.
  • Reduce the threat and we reduce the pain.

Obviously there’s a lot of subconscious stuff at work when we experience pain. If we want to tie our shoes or turn the ignition key of a car, we have to consciously take action to make these things happen.  In contrast, we don’t have to think at all in order to feel pain. We feel pain without having to consciously do anything. However, research into pain reveals that we can often actually reduce our pain via cognitive processes.

One of the most powerfully fascinating aspects of pain management involves consciously considering pain and whether or not we’re actually under threat. Emerging research strongly indicates that pain management can be made more successful by educating a patient about the whole pain process. Understanding the process at work and recognizing that pain DOES NOT equal injury and that it IS NOT a threat to our health or life can be hugely powerful. For instance, there’s this analysis of research titled. Patient education interventions in osteoarthritis and rheumatoid arthritis: A meta-analytic comparison with nonsteroidal antiinflammatory drug treatment. The conclusion is this:

 Based on this meta-analysis, patient education interventions provide additional benefits that are 20–30% as great as the effects of NSAID (non-steroidal anti-inflammatory drugs) treatment for pain relief in OA and RA, 40% as great as NSAID treatment for improvement in functional ability in RA, and 60–80% as great as NSAID treatment in reduction in tender joint counts in RA.

Here, patient education offers benefits beyond that seen with drug treatment alone.

Exercise Biology explains pain:

Exercise Biology is a fantastic, very thoughtful site full of very useful information. It’s written by Anoop Balachandran. He’s gone to admirable lengths to include only evidence-based information and science. It’s not just opinion. One of the best articles on his site deals with pain science. It’s called What should fitness professionals understand about pain and injury? and it does a great job of breaking down a complex subject digestible pieces. (Todd Hargrove at Better Movement also does a great job discussing pain in a similar way.)

Very pertinent to my experience is Anoop’s discussion of how to desensitize or calm down a nervous system that is overly sensitive to a perceived threat that no longer exists. He describes the top-down vs. the bottom-up (find-it-and-fix-it) approach:

Top Down: Basically, means changing your attitude, beliefs, knowledge (neurophysiology of pain) about your pain and in turn, lowering the threat value of pain. People get hurt, they experience pain, healing follows, and they recover. But in some folks the pain lasts forever. And why is that? According to one of the most well-accepted models – the fear-avoidance belief model –  people who have heightened fear of re-injury and pain are good candidates for chronic pain. Lack of knowledge or incorrect knowledge, beliefs ( hurt always means harm, my pain will increase with any activity and so forth), provocative diagnostic language and terminologies used by medical therapists like herniated disc, trigger points, muscle imbalance, and failed treatments can further heighten this fear or threat . So education to lower the threat is THE therapy here. We now have some very good evidence to show that just pain physiology education or the top-down approach is enough to lower pain and improve function 5.

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Bottom Up approach: The bottom-up approach is what we see around us: surgery, postural fixing, trigger point, muscle imbalance, movement re-education, manual therapy, acupuncture and the list keeps growing. Almost all treatments out there are trying to lower the nociceptive drive without much consideration to the top-down approach. This is solely because these treatments are based on the outdated model of pain. We now suspect that positive effects of manual therapy may be due to neural mechanisms than the tissue and joint pathology explanations that is often offered. So even the bottom up approach is working via de-sensitizing the nervous system. Although not intended, there are top-down mechanisms clearly at work even in bottom up approaches( like the placebo effect, a credible explanatory model, the belief in the therapist) .

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So what we you need is a combined approach that takes into account the “entire individual” and that’s where the biopysycosocial model of pain treatments walks in. The bio psycho addresses the biology (nerves, muscle, joints), psychological ( beliefs, thoughts, fear) and social aspects (work, culture, & knowledge). 

Pain self-talk: “I’m not in danger.”

My Achilles started feeling a lot better once my running biomechanics were cleaned up (the bottom-up strategy.) I still had some sporadic discomfort though. In reading up on pain and the brain, I realized it was time to apply the top-down method. I had several internal conversations with myself. I said something like this: “I’m not under threat. My Achilles is strong. It won’t break. I’m safe and strong and I’m ready for anything that comes my way.”

I started feeling a little like Stuart Smiley as I gave myself these pep talks–but guess what!–they worked. Literally within 48 hours my residual pain was gone! This conscious thinking process seemed to influence the unconscious pain process to a very favorable result.

The pain neuromatrix

This model is known as the pain neuromatrix. and it is very powerful stuff. It may sound odd this idea that pain and injury aren’t the same, and that pain can be changed literaly through education. I haven’t made any of this up though. This is what the researchers are finding.

My ACL injury and pain

 I sustained an acute knee injury that includes a torn ACL. Did it hurt? Oh yes! It was a sudden change that my brain rapidly assessed as a significant threat. The result of the injury is instability in my knee and I can’t move as much or as well as I could prior to the injury. From an evolutionary standpoint, I’m at a disadvantage for survival. Pain is helping me avoid further damage. I will most likely undergo an ACL reconstruction (I hope to know for sure next week.) with plenty more pain to go along with it. But I’m not worried.

I went through 10 years of weird chronic pain (primarily low-back pain) that didn’t have an obvious cause. I obsessed over it and dreaded the pain constantly. I missed out on perhaps my best potential years as an athlete. I overcame it though.  (Much of my relief came from the bottom-up approach of fixing a lot of biomechanical issues–which ultimately reduced the threat level to my brain.)

Now with that perspective and my current knowledge, here’s how I see my knee injury:

  • I’m highly optimistic that I can be fixed and that I can return to all the activities I love.
  • I’m exercising as much as possible while at the same time avoiding pain. In this way I’m calming my brain and minimizing any feelings of depression, 2nd guessing, or any “woe-is-me” thinking.
  • The threat level via my knee will be high. Therefore:
    1. I must be patient and diligent with my rehab. I will!
    2. To reduce threat, my return to exercise (particularly Olympic lifting, trail running and skiing) must be gradual and non-threatening.

More resources:

Lorimer Mosely is one of the foremost pain experts on earth. Here he lectures on pain. Around the 7 minute mark he discusses his own experience with a very dangerous yet painless wound. The whole thing is fascinating but perhaps a bit long for some. If you’re in pain though I strongly suggest you watch it.

Also, here’s a link to an interview by Bret Contreras with physical therapist Jason Silvernail. Many good questions are asked and very well-informed answers given. Again, it might be long for some of you but the information is just hugely valuable.

Remember, learning about pain can help you overcome pain! Reading and listening to those who understand pain can be hugely beneficial to anyone who suffers. Below are more resources.

Informative sites:
www.somasimple.com (excellent forum)
www.bodyinmind.org
www.forwardthinkingpt.com
www.bboyscience.com
www.saveyourself.ca
www.bettermovement.org
www.thebodymechanic.ca

Excellent books:
Beginner Level

  • Explain Pain by David Butler & Lorimer Moseley (This is a must read)
  • Painful Yarns by Lorimer Moseley

Intermediate Level

  • Pain by Patrick Wall
  • The Challenge of Pain by Ronald Melzack
  • Sensitive Nervous System by David Butler
  • The Back Pain Revolution by Gordon Waddell
  • Topical Issues in Pain by Louis Gifford
  • Therapeutic Neuroscience Education: Teaching patents about pain by Adriaan Louw ( a book on how to do the top down approach)
  • Pain by Lorimer Moseley (DVD)

Major Detour On All Fronts

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The good news is I have a radically brand new challenge in front of me. This new wrinkle is going to help me learn new discipline and it will push me to learn all sorts of new things. I’ll be able to relate to a large population of people in a way that I’ve never been able to relate before.

Wonderful! 

The bad news is I don’t want anything at all to do with this new “wonderful” opportunity. See, on Saturday I tore my right ACL while skiing.   (At the very least I’ve torn the ACL. That’s according to the ER evaluation.) New skis, steep terrain, poor visibility all combined to pinwheel my down the slope and jackhammer my knee into some degree of twisted gristle. (I’ll also admit with some degree of dumb pride that I resumed skiing and made it to the bottom on my own. Probably not a great idea but I’m looking for all the silver to the lining of this cloud.) I’ve been feeling fantastic lately. I’ve been strong in the gym and I’ve been running a lot. Whatever the opposite of that is, this is it.

So all my high falutin’ lofty running goals are going to take a back seat to 1) surgery and 2) a very gradual return to normal human movement. Running, biking, hiking, lifting weights and all that fun stuff is way out there on the horizon. That said, I have every intention to resume all my favorite activities. No way in hell do I intend to give up the active outdoor lifestyle that I love so much.

We shall get to know each other very well.

We shall get to know each other very well.

In less than 24 hrs I’ve learned some useful things about ACL reconstruction. First, there are two basic types of ACL reconstructions. The autograft uses my own tissue either from the patellar tendon or hamstring tendon. The allograft uses a cadaver tendon. There are advantages and disadvantages to all these different strategies. I’ll probably discuss them further in the future.

I hope to get an MRI and further evaluation as soon as possible. I’ll call the doc tomorrow to see when I can get in. I want to get on this thing aggressively and soon. I may learn that there’s more damage than simply a torn ACL. There are other tendons and minisci that could also be damaged.

The full recovery progression on this condition seems to be about a full year, and that’s full-on aggressive multi-dimensional movement. More good news here is that ACL reconstruction has been around for a long while. Lots of high-end powerful athletes go through this process and come back to perform at very high levels. From my understanding, the results can be excellent.

 

 

 

 

The Final Victory Against My Heel Pain Part I: Addressing the Biomechanics

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I’m really thrilled to be writing this post because it seems I’ve finally truly gotten rid of a chronic heel/Achilles/plantar fasciitis issue that has been with me for a long time. (I’ve said this before and I’ve been wrong, but for the record I’ve been running a lot and my heel hasn’t felt this good for this long in years.)

This thing has been with me for maybe three years. It’s never been enough to really knock me out. It didn’t derail me from my first marathon and subsequent 10-milers and half-marathons. However, several weeks ago I did a long trail run and it felt like a nail had been driven into my heel. I figured it was time to sort this out. The solution has been a mix of biomechanical and running technique adjustments, and a deeper understanding of pain science.

Before I met with anyone I put a green Superfeet insert into my shoes. I’m a minimalist shoe advocate.  I don’t want to rely on a crutch but I’m also very much willing to do whatever is appropriate to solve a problem. A lot of what I’ve read for addressing heel and Achilles problems suggests putting some sort of insert into a shoe. The idea here was to unload some of the muscles and structures that hold up the foot, including the Achilles. I’m still using the inserts on a lot of my runs but I rarely wear them at work and I do some of my runs with without the insert.

I next met with a couple of guys with a lot of great knowledge and experience. Mike Terborg and Nick Studholme were both very instrumental in my progress.  Mike is a performance and injury recovery specialist in Boulder and Nick runs Studholme Chiropractic. Mike is heavily influenced through John Hardy and the principles of FASTER Global which teaches a process of biomechanical reasoning. Nick studied under the innovative physical therapist Gary Gray. Both guys speak much the same language when it comes to movement and movement analysis.

They both have tremendous ability to explain what they see and communicate the changes they thought I should make. They both used a fantastic and powerful video program called Spark Motion which was created by Nick and a group of other guys. This was just an amazing way to record and analyze movement. Spark is a great tool that I need to look into.

The visit with Mike Terborg: Running adjustments

I first visited with Mike in Boulder a few weeks ago. We spent a couple of hours looking at how I moved. The major issue we found was prolonged eversion of my left foot. The foot stayed in contact with the ground for what seemed a long time. Mike explains his observations and thought process:

“Adhering to the Biopsychosocial or BPS model of pain (vs the Postural-Structural-Biomechanical model), we couldn’t say for sure what was causing the pain other than it could be a combination of things including but not limited to biomechanics. You had chronic pain of the plantar fascia, like to run, and wanted to be able to run more without aggravating this injury so we needed to look at your physiological skills and tendencies relative to gait. We cannot say for sure that eversion and dorsiflexion of the subtalar joint caused the injury (because these are natural motions of subtalar joint and thus normal motions for the PF to decelerate), but we can deduce that less loading of the plantar fascia (less dorsi/eversion) might be helpful in reducing the amount of stress on the PF during running. Our hope was that less stress/load during gait may allow you to run pain free for longer. In sum, we can say for sure that we crossed some type of stress threshold (bio, psycho and or social), so we wanted to ask your body what happened if we backed off on the biomechanical load to the pissed off tissue. 

“Your ranges and sequencing in the breakout evaluation all looked good, so we went straight to your running technique. Using Spark Motion for gait analysis, we deduced that it was possible for you to run in a way that reduced the stress to your PF and apparently that helped. The drills were all part of a progression to not only teach your body the skills and sequence of a more rapid gait but to train your ability to sustain that gait for longer periods of time (strength endurance of a skill). Nothing fancy, just following biomechanical reasoning to look for clues and strategies.” 

I really like Mike’s explanation of the process. He puts his explanation in a very honest way. In saying that we don’t know for certain why the pain is there, nor do we understand exactly how or why it might go away, he reflects the current cutting edge of pain science which reveals that pain is in many ways a baffling mystery.

He directed me to several exercise progressions of which here are three:


We changed my running gait along these lines:

  • Put less pressure through the heel into the ground. Let the heel touch the ground but only lightly.
  • Quicken the stride so the foot stays in contact with the ground for less time.
  • Swing the right leg through faster to facilitate less time on the ground of the left foot.
  • Run with a metronome set somewhere between 170-190 bpm.  This quickens the stride rate. Experiment.

The resulting new gait felt like I was some sort of prancing fool–La la la la laaaa!!!–dancing through the daisies.  Fortunately the video Mike shot of me indicated that in fact I just looked like I was running with a quicker step. (I could in fact go running in public this way.) Finally, Mike also suggested I visit with Nick so I did.

Analysis from Nick Studholme & fine tuning the lower leg

Nick put me through a muscle testing process and winnowed out some weak and unstable muscles in my lower leg. Specifically, big toe muscles known as flexor hallucis longus, and flexor hallucis brevis weren’t working up to par. The fibularis muscles (aka peroneals) were also a bit off line.

Taken together, when these muscles work they create and control plantar flexion and inversion of the foot as in the push-off of running or walking, and they create/control dorsiflexion and eversion of the foot as when the foot hits the ground.

Of great importance is the ability to anchor the big toe to the ground while the body passes over the foot. I was missing the mark. Nick taped my foot in a way to help facilitate this anchoring and he showed me several exercises to help me feel, create and control better big toe function while running. These exercises were similar in nature to what Mike showed me.

It’s several weeks later and what are the results? The heel and Achilles quickly started feeling better. I did a series of short interval type runs. The quicker pace (around 175-180 bpm) was challenging at first. I didn’t want to become exhausted while running and lose the technique, thus I only ran 1 or 2 minutes at a time. and walked in between. (Running with my dog tends to be a good way to break up the running with walking.)

Some discomfort remained for a couple of weeks in a stubborn way. It wasn’t terrible but it was hanging around like it was ready to pounce. I was worried that there was something we might be missing. This last bit of hanging-around heel trouble would be gone within 48 hrs after I reviewed the current ideas on pain and the brain. I’ll discuss that in the next post.