One of the great things is you can see how shoe styles have changed.  One of the best things for me is these open back shoes.  When I first went into medicine, nobody wore those.  They were odd clogs, and nobody wore them.  Now, they’re all over the place, and if you have this problem, you can get a varying heel height.  You can get an open back shoe that doesn’t rub on the area, and a lot of times, that will give you symptomatic relief.

We use cortisone injections for a lot of different things.  This is definitely one where you do not want a cortisone injection in your Achilles tendon.  It increases the chance of rupturing the tendon.  So, stay awake from injections.  I had two people come in last month that had cortisone injection in there, and they ruptured them.  So, cortisone wipes out the inflammatory response, and whatever healing response that you have is wiped out.  Then, it also weakens the tendon.  Cortisone injection is okay for painful joints like the knee joint if you have arthritis in your knee.  A lot people will get them in their shoulders, but you need to use them judiciously.

So, we don’t need to get too into the classification, but what we’re saying about tendon is here’s normal tendon as it attaches on to your heel.  Sometimes, it can be involved in the mid portion of your tendon.  The tendon can just degenerate, and what I usually tell patients it’s like a rope that starts fraying.  When you think of a rope, when it starts fraying, it gets wider.  That’s what happens to the tendon.  You have these longitudinal fibers in the tendon, and as they get inflamed and start breaking down, they usually get wider.  That’s what you feel when you feel the nodules or the bumps in your tendon.

There’s an area of the tendon that has a poorer vascular supply, and it’s right here, usually about an inch to two inches above your heel.  That area doesn’t repair itself well, and you see this.  People get tendon problems in their middle age, and there’s several tendons in the body that tend to fail.  It tends to be in areas where the tendon doesn’t have a good blood supply.  So, all our tissues need nourishment from the blood.  When they get as good a blood supply or nourishment, they don’t repair themselves as well. Again, this is 2 to 6 centimeters above the heel.  There’s fewer blood vessels so there’s less capacity for it to heal.  Again, people with tendinosis tends to be the up in the tendon.  They tend to be runners, oftentimes, with a gradual onset.  They’re tender throughout the length of the tendon.

Usually, we don’t need a lot of diagnostic studies.  The MRI doesn’t give me a lot of information.  As long as the tendon is working doesn’t give me a lot of information on how to treat it.  The MRI, they’re very sensitive, and it will tell you the full extent of the involvement of the tendon.  Usually, the MRI will make the tendon look much worse than what it is.  So, you have to be careful with what you take away from it because it’s such a sensitive test that it makes the condition look worse than it probably really is.

The surgery for it is just debriding the bad part of the tendon.  In a nutshell, the more that you take out, sometimes you have to reconstruct the tendon defect that is created by taking out the bad tendon.  We easily do a longitudinal section and remove what looks bad and repair the rest.  Occasionally, we’ll take another tendon from the area to reconstruct it or reinforce it.  This is an MRI, and it shows you some of the diseased tendon.  Then, this is looking at it in surgery.  You see the tendon here.  We made an incision along the medial side of the tendon, and you cut the bad portion of the tendon.  If you take out more than 50% of the tendon, we usually reconstruct it with something.  If we take out less than 50%, we can usually just sow it up.

Surgical recovery is similar to Achilles tendon rupture.  If you don’t have to take out more than 50% of the tendon, usually recovery is a little bit faster than a rupture.  We usually have you in one of those protective boot and open-back shoe for about 3 months.  Then, usually, it takes you about 8 to 12 months to really get all your strength back.  The worse part of the surgery is the first 2 months.  You’re kind of limping around for the first 2 months.  After that, from month two up to a year, you’re basically just gaining strength.  For people who run or do heavy exercise, usually you’re back to jogging around 2.5, 3 months, but you’re not up to the point where if you’re a 10-mile runner, you’re not doing that for a good 8 to 12 months.

So, the treatment that’s in between the newer, we’ve been doing a study on it, is this stuff called PRP.  PRP is platelet rich plasma.  Basically, the appealing thing about is it’s your own tissue so you don’t have to get anything from anybody else.  Basically, they draw blood from you as if you were doing routing blood work.  You take your blood, and you put it in one of these centrifuges.  The centrifuge spins it down, and it isolates the platelets.  The platelets are cells in your blood, and the way it works is there’s a lot of growth factors inside the platelets.  So, we take that concentrated part that concentrates down to about 3 to 4 cc, and we inject it directly into the tendon.  So, you’re putting the growth factors on the bad part of the tendon trying to incite the healing response with the growth factors, and the tendon will somewhat repair itself.

We think that it works well.  Platelet rich plasma has been used well in a lot of the areas of the body and in a lot of soft tissue and places that haven’t typically healed well.  So far, our results have been pretty good, and out of all the people that we’ve done, we haven’t done surgery on any of them.  So, it has prevented people from taking the step to saving surgery.  Obviously, the advantage of this is there is essentially no recovery time.  So, you come in.  We usually do them on Fridays, and you put ice on it over the weekend.  Then, the next week, you’re walking on it again, and you can go back to your regular exercise program.  So, I usually tell people this is something that’s very low risk, and probably the worst-case scenario is it doesn’t work.  There’s really no risk of getting any infection.  You don’t have any implant on your body or anything like that.  So, oftentimes, it helps and gets them to the point where they don’t need surgery.

Platelet rich plasma is still investigational.  Again, very low risk, very limited recovery time.  So, you don’t really have to stay off work or anything like that.  This is generally not covered by insurance, but the nice thing about it is that it’s not very expensive.  So, again, it’s probably less expensive than buying a pair of orthotics.

Any questions about Achilles tendonitis?  Yes, ma’am?

[38:09]

What else have we used the PRP for?  When it first came out in orthopedics, they used in fractures that didn’t heal, but it’s been used extensively in rotator cuff surgery because rotator cuffs are typically a tendon that is necessary.  So, usually you don’t want to cut the tendon out, and it’s one that has a very poor blood supply.  In rotator cuff surgery, in general, it’s very hard to get the tendon to heal.  Sometimes your symptoms will go away, but what my shoulder partners work on is trying to figure out better ways to make the tendon heal.  So, it’s used more extensively there.

It’s been used now, when people are injecting, in tennis elbow, in soft tissue tendons.  The other big application of it that people were putting it in knee replacements, trying to decrease the blood loss, and those are probably the biggest orthopedic applications of it, but really, anywhere that you do surgery.  Plastic surgery uses it, too, where you’re trying to get soft tissue tendon or some type of soft tissue to try and heal.  A lot of people have used it to augment the healing.

Now, the peroneal tendon, this is the last one.  So, if everybody could try to stay awake, we will wrap it up in about five minutes.  The peroneal tendons are on the other side of your ankle. This is a picture showing the peroneal tendon tear.  So, this is the lateral of the outside of the ankle.  So, this is the ankle up here.  The foot’s over here, and this, right here, is your ankle bone or what you feel on the outside of your ankle.  The tendons are right behind.  There’s two tendons right behind your ankle, and these tendons, when you have trouble them, they do one of two things.  They either tear, which is more common in middle aged people, or sometimes you can have a sprain, and they pop out of their sheath.  So, you can have a click over the fibula.  So, that’s a popular thing.  It happens a lot of teenagers.  They drive their parents crazy by popping their knee.  You see them moving it back and forth over the tendon.

Again, the more common thing we is the middle aged people with the tendon tear.  Usually, the pain is behind the lateral side or your ankle bone.  In the first part, we spoke about flatfeet.  One of the more common alignment things that you see is people with this side of the ankle tend to have a really high arch.  So, they have a really high arch and walk on the outside of your foot.  You’re more likely to get ankle sprains and these tendon tears like this.

This shows the two tendons.  This is your ankle bone here, and the peroneus brevis is the one in the front, and the peroneus longus is the long one behind it.  So, in the subluxation where the tendons dislocate over the bone, it’s usually younger people.  It’s usually a traumatic event, and it’s usually the peroneus longus.

So, in the tendinosis where you get tendonitis or the tendon starts to tear, usually what we try to do, as with a lot of things, is change the alignment of the foot.  So, you can put a lateral heel wedge in. Usually, there’s physical therapy.  The reason we use so much physical therapy on these tendon problems is that it helps mobilize the foot, but the physical therapists have a lot of modalities like ultrasound, heat and cold, and all these things that will often calm down the inflammation of the tendon.  Oftentimes, if you get the inflammation to go away, your blood or your symptoms will go away.  So, we use a lot of physical therapy and bracing it so that when you do physical activity, you’re not stressing the tendon too much.

In the treatment of the dislocated peroneal tendons, usually there’s not a lot that you can do to fix that.  I don’t know if any of you are baseball fans, but back when the Red Sox were in the World Series and Curt Schilling had his ankle hurt and they took him over to the guys at Harvard.  They put a big stich right through and his tendon.  He had this dislocating peroneal tendons.  They did that so he would make it through the World Series, and stop the popping.  When the World Series was over, they went in and fixed it.  So, that’s usually a surgical problem.  There’s really not much you can do to make the tendon stop snapping other than fixing it with surgery.

The other thing we do with the peroneal tendon tears is most them, if you catch them earlier, you can repair them.  For the ones that are far gone, since there’s two tendons there, you can repair it to the one next to it.  So, this is one of the conditions in foot and ankle where an MRI is very helpful.  So, for pain on the outside of your ankle, sometimes an MRI can help you, and it can make the diagnosis of these tears and makes your decision making a little bit easier.