Recurring Tendinitis (primarily peroneal): Email Advice

Hi Dr. Blake,
I have had recurring tendonitis diagnosed in various tendons in my lower leg and foot over the past 2 years. Started with overuse sesamoiditis, posterioal tendonitis and peroneal tendonitis. MRIs of foot, knee and even back after an EMG because of calf muscle atrophy. I am a climber so this constant injury is very frustrating to not be able to walk lain free, let alone climb. A podiatrist and now an orthopedic surgeon recommend a tendon sheath injection for the Peroneal tendon issues. I have pain at attachment under arch and at side of calf below knee. Weakness and increase pain wih movement. Also tendon pops at ankle. I have done pt and various therapies only to platue. Do you thimk the shot is best way to go? What questions do I need to be asking to make sure it is safe?
Thanks, Sarah 

Dr Blake's response:

Sarah, sorry for my delay in responding. I am assuming that the MRIs only came back with tendinitis and no tears. The PRP injections are gaining popularity, make some sense, but I just have no experience with it to recommend clearly. Definitely no cortisone into the muscle, tendon or sheath for fear of rupture due to transient weakness (which could last up to 9 months). Review the blog article on BRISS for tendinitis. See if there is anything missing in your treatment. Have you been adequately immobilizing in a below the knee removable boot for up to 3 months? Do you then to supinate excessively even with orthotic devices? When you return to activity, do you just go back to an overuse situation? Sounds like unless you can not get the tendon strong, it will be permanently the weak link for activities. How can it be made stronger? Or why haven't the PTs been able to make it strong? Sorry more questions than answers. Rich 

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

Plantar Fasciitis and Achilles Tendinitis: A Common Duo

Dr. Blake, I found your blog online and found them a fascinating read. I wonder if you can shed some light on my foot problem. I have plantar fasciitis on both feet and Achilles tendon insertional micro tear (insertional Achilles tendonitis?). I have had them for more than a year, been seen by my podiatrist 4 times. I am still in pain from both problems.

• Nov. 2011.       started noticing pain in bottom of right heel at the first steps of the morning

• Nov. 2011.       took Ibuprofen for 2 weeks per primary doctor’s advice and stopped daily 2-mile run since then on

• Jan. 2012,       while the condition of right heel is getting worse to 8 out 10 pain scale, I started noticing pain in bottom of left heel at the first steps of the morning. I started wearing orthotics since then.

• Feb. 2012.       seen by a Podiatrist. Was told to do regular stretching.

• Mar. 2012.       over stretched the Achilles tendon/heel bone insertional area. Having pain in the insertional areas of both feet since then. Stopped stretching since then.

• April-Sept, 2012, elevate my feet as much as I can during the day. Ice them before I go to bed at night. Symptom is getting better. Pain level improved 5 out of 10 scale.

• Dec. 2012.       Started arch stretch. Plantar fasciitis pain appear to get better, but very slowly

• Feb. 2012.      Started to massage calf muscles, plantar fasciitis pain appear to get better, but very slowly

• March, 2012. Started to have a lot more pain, new pain, in the lateral side of the heel of both foot.

• My doctor told me to stretch the calf muscle. But even a very gentle stretch will cause the insertional area quite painful.

I wonder whether there is any cure for me? Thank you.

Dr Blake's comment:

     Thank you so very much for your email. I am gradually catching up from before my little Hawaiian vacation, so I apologize for my delay.

Sunset from Waikiki Beach, Oahu, Hawaii

Most people know that the plantar fascia on the bottom of your foot originates from the achilles tendon fibres that engulf the heel bone. If you are lower on the evolutionary change, there is a greater connection between these 2 structures. Apes can use their ankles like hands so need these two structures connected. So, no matter where you are at  in the evolutionary process, you can develop pain in one structure first, then another. This, in your case, is what is being treated. But, is it correct? You can consider the achilles tendon fibres grabbing the heel bone from the back, both sides, and bottom (like a hand), ready to lift the weight equivalent to 10 times your body weight. And, it is hard to stretch the insertional achilles fibres into the heel bone since they are attaching into the bone. Typically stretching and massaging, if not done perfectly, can irritate the fibres more than bring them relief.

As you are being treated for tendinitis/fasciitis, and it is not working well, there are 2 logical explanations. The treatment is just not tailored enough (individualized) to you or the treatment is not addressing the correct diagnosis. First of all, both the plantar fascia and the achilles tendon attach into the heel bone (calcaneus). This could easily be an injury to the heel bone with pain from protection or compensation in the  plantar fascia and achilles. So, I would look into obtaining 3 tests that can greatly help with the diagnosis: x rays, an MRI, and a bone scan. The x rays have the least likely chance of helping, but they may point to something important. Even if you had to self pay for these tests, the $1200 (San Francisco Bay Area prices) would be worth it. This would 100% rule in or rule out a bone problem that needs to be dealt with differently than you are treating yourself. 

Second of all, the plantar fascia and achilles have fibres of the sciatic nerve running through them. I have personally misdiagnosed sciatic nerve problems as plantar fasciitis and achilles tendinitis numerous times. It is easy to do, but when the patient does not respond to normal treatment, you look deeper. Neurologists and physiatrists are the nerve test people. See if they can make some correlation to your pain and the sciatic nerve. This may require a nerve conduction test. Treatment for this syndrome also quite different. The sciatic nerve hates to be stretched, but the technique of neural flossing may work. 

Finally, perhaps the treatment you are getting for achilles/plantar fasciitis is not correct. When you have any type of tendinitis, see my post on BRISS. This stands for Biomechanics, Rest, Ice, Stretch, and Strength. It is the 5 areas that should be addressed simultaneously in treating any tendinitis like achilles tendinitis and plantar fasciitis. You make changes in the biomechanics of shoe gear or activities, you use rest or activity modification principles to keep the pain level between 0-2, you use ice and other anti-inflammatory measures to calm the tissue down, you do pain free stretching, and you begin arch and achilles strengthening the day you begin to have pain. Go back to square one with your rehabilitation. See the link on BRISS. Read all the posts regarding achilles and plantar fascia. Get some of the above mentioned tests to rule in or out other causes of heel pain. I sure hope this points you in a good direction. Rich

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

     

Achilles Tendinitis: Email Advice

Hi Dr. Blake,

I think the orthotics are working well.  If you wouldn't mind making me another pair (maybe with a longer pad this time), and mailing it to me.

Btw, I noticed that my left Achilles is a bit sore/tight so I started wearing my night splint at night, in addition to stretching.  Do you think that will be enough to prevent Achilles tendinitis?

Thanks for everything.

Beth

Beth, I will go ahead and design another pair. When you are dealing with any tendinitis, the acronym is BRISS--Biomechanics (what causes it and what can help it), Rest or Activity Modification (to avoid irritating daily), Icing, Stretching, and Strengthening. See the link below to give you the generalizations. You can also explore the blog for more specifics on each area. In summary, the treatment should be well rounded, and not just limited to stretching. Hope this helps, Rich. Please feel free to email with other thoughts. 

  http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html 

And here are 4 videos from my YouTube channel (drblakeshealingsole) which also may help.