Posts Tagged ‘fitness’

Chronic Tendinopathy of the Achilles tendon and Plantar Fascia

December 13, 2015


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.


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



Buying Athletic Shoes for Your Foot Type

February 28, 2010

Buying athletic shoes can be a very daunting task, especially with the never-ending options of shoes found at stores. However, there is a science to athletic shoes, so you can find a pair that are best for you and decrease the chances of injury to your feet with some fundamental knowledge.

Before buying an athletic shoe, you must know what type of foot you have. Of course, there are subtle differences in everyone’s feet, but in general, there are three main foot types and athletic shoes, subsequently, are made for each of these foot types.

Foot Types:

1. Neutral foot: A neutral foot has a medium arch, which allows the pressure and force of running to be evenly distributed throughout the foot.  Additionally a neutral foot has an adequate amount of pronation, a movement that occurs during weight bearing where the bottom aspect of the arch moves toward the floor. Therefore the arch gets lower and the foot is more flexible in a pronated state. Since a neutral foot has the necessary amount of pronation, this foot is flexible enough to absorb the pressure of running and walking and adjust to changing terrain.  Also, a neutral foot has an adequate amount of supination. Supination is a movement of the foot where the arch of the foot rotates off of the floor creating a higher arch and a more rigid foot. With an adequate amount of supination, a neutral foot is rigid enough to push off the ground without causing injury. Recommended shoes for a neutral foot type are stability shoes.

2. Over Pronated/Flexible foot: This foot type has a very low or flat arch, which increases pressure on the inside of the foot and big toe during walking or running. This usually results in an increase of skin thickness on the inside of the big toe and ball of the foot.  Also, this type of foot is more flexible than a neutral foot. In the pronated position the foot is not rigid enough to push off the ground. Since an over pronated is a more flexible foot, motion-control running shoes are recommended for this foot type.

3. Over Supinated/Rigid foot: An over supinated foot has a very high arch, which increases pressure throughout the heel, the outside of the foot and ball of the foot. Compared to an over pronated foot, an over supinated foot is rigid and is not able to absorb the forces applied to the foot than the other foot types. An over supinated foot/rigid foot type benefits more from a cushion running shoe.

Shoe Types:

1. Motion control shoes: This type of shoe is best for patients with excessive pronation or a flat arch. The back of the shoe that cups the heel is known as a heel counter. The heel counter in a motion control shoe is rigid to prevent excessive pronation that occurs in a flexible foot. Additionally, the outline and shape on the bottom of motion control shoe is straight and broad at the front of the foot.  This shape is also designed to improve stability like have a wide wheelbase on a car.

To test a motion control shoe, grasp the heel counter with your hand and squeeze the heel counter. The heel counter should not deform with compression of your hand.

Another way to test for motion control is to grab the front of the shoe with one hand and the back of the shoe with the second hand and twist the shoe. The shoe should not deform with the twisting motion. The final test to determine the amount of motion in the shoe is to bend the front and back of the shoe together like a book. The bend of the shoe should be at the ball of the foot where the foot pushes off the ground during activity and should not bend in the middle of the shoe.

2. Cushion shoes: This type of shoe is best for patients with excessive supination or a high arched rigid foot. Cushioned shoes decrease pressure on the feet by absorbing forces transmitted from the ground while running. The outline and shape on the bottom of cushion shoes tend to curve at the front of the foot with extra padding at the front and middle of the shoe. Additionally, cushion shoes tend to have an hourglass shape when looking at the sole where the middle part of the sole is narrower than the front or back. Compared to motion control shoes, it is easier to twist a cushion shoe. Additionally, when bending the front and back of a cushion shoe together like a book, the bend is also at the ball of the foot, but the amount bend is greater and easier to perform than a motion control shoe.

3. Stability shoes: This type of shoe is recommended for a neutral foot type. This shoe has components of both a motion control shoe and a cushion shoe. The outline and shape on the bottom of stability shoe is semi-curved at the front of the foot. This type of shoe has cushion for absorbing forces from activity, but also like motion control shoes, has a firm heel counter, but is not as rigid as a motion control shoe.

General Shoe Fitting Rules:

1. Measure both feet standing

2. Try on shoes later in the day when feet are more swollen

3. Try on shoes half a size larger to compare fit

4. Leave one finger width from the end of the longest toe to the end of the shoe

5. Wear the shoe indoors first for 10 minutes or more to make sure it is comfortable

6. Shoes should not need a break-in period they should be comfortable when you try them on.

7. Make sure nothing pinches you inside the shoe

8. Do not wear a shoe for the first time in a race.

Replacing Shoes:

Shoes should be replaced about every 300-500 miles of running or walking or 45-60 hours of a sport activity. If there is creasing around the shoe lining, new athletic shoes must be considered. Another test to determine when to replace shoes is by seeing whether or not the shoe is uneven when it is placed on a flat surface.

Podiatrist: Get on your feet

December 5, 2008

Fitness SeriesAs both a health care 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.

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

November 18, 2008


Yesterday at the gym.

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 will 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 all the time.