Achilles Tendinitis in a Masters Track Runner: Should He Race?

Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, thanks for joining me again at the Performance Place Sports Care Podcast. This one today is actually, it's on an ultrasound that I did in office here. I thought it was really, it was a really fun one, actually. It was a master's track athlete, and it was for an Achilles tendonitis. I don't know if any of you know, but I actually conducted a study for one of the credentials that I have.

It was an ultrasound study, and the study, I should actually probably reopen it because I didn't have enough samples. I didn't have enough people who came in to participate with it, but I had a deadline. I had to finish it. So anyways, the study was on self-diagnosis or accuracy of self-diagnosis for patients. And what we were targeting was Achilles tendonitis in runners. And the reason why I did Achilles tendonitis was because it's really, really easy for, most people know what Achilles, the Achilles is. I mean, they can at least point to it. They know it's on the ankle. They know roughly kind of where it's around. So they should kind of get that diagnosis right. I mean, most of the time. So anyways, I had this study open.

We found that less than half the people actually got the correct diagnosis. It was really interesting to see. But anyways, so this master of track athlete, he's also a running store employee locally in the area here. And he called up because there was a, to get a bunch of the participants, I wanted to target runners and make sure that, I mean, store employees or running store employees would be good ones. So I'd say, Hey, there's a study. Can you go take it? It doesn't cost anything and so on. So I'd put out a bunch of feelers to the local, uh, like running stores and, and, uh, track clubs to see if I can get people. But so this guy, uh, he emailed back. It was like, um, I think I finished it over a year ago. Um, the study anyways.

So it was kind of published and, but he said, Hey, I think I got Achilles tendonitis. Can I come in and see, is the study still open? So I said, yeah, you know, like it's the study's not currently open, but, uh, I can take a look for you. You know, like it's a really quick once over. And, um, that's one of the reasons why I actually did the Achilles study as well. I knew it was going to be really quick to do. Um, cause you can see on an ultrasound, you can see within, I mean, less than 30 seconds. If the person has an active condition right there. Um, so this guy, he had left sided, uh, backside of ankle pain. So right where the Achilles tendon is, if you don't know what the Achilles tendon is, by the way, it is the big tendon on the foot on the backside. Uh, it's the one you can feel the most easily. Uh, it's the thickest one there and it attaches to your calf or it attaches the calf muscles to the heel.

And it allows you to, I guess, point your toe when you're sitting there and listening to this podcast. So he wasn't getting any better and he wanted to race again at some upcoming meets. So he was kind of want to figure out what his risk reward was. Like, could he start running again? Like, should he start running again? Um, so anyways, he came in and I could tell he was pretty frustrated. It was been about three months or so since he'd had it. Um, he did some, he did some rehab and he did some stuff at home as well. Um, if I'm recalling correctly, I know he did some like ice and heat. He rested it for a while. I know he wasn't running when I saw him. Um, but he'd done some hip and core stuff, some stretching. Um, but he kind of did this, the strengthening or core stuff really sparingly. It sounded like it wasn't like a target part of his program at all.

But, so when we did the ultrasound, um, I, he was pointing at a couple other spots around his Achilles. So I looked at them and they were actually normal. And, but I, when I got over the Achilles, it, I mean, it was just rampant, full of vessels and vessels are, so blood supply. Um, so the blood supply in the area, I mean, it's really, that's more of like an active, active condition. Um, I believe in the study that when I had it, there was only one person where I saw that they had this much activity in their, in their heel. And in this lady, actually, she had been, she'd had it for about four years or so. It was really tight in the morning. It got better when she ran. And she, she didn't seem super concerned about, uh, improving it beyond that. Cause it seemed to loosen up enough for her to run.

Uh, but, but this guy, he was really wondering if he was going to damage it further if he started to run. So when I saw that, like those, those vessels actually, um, I was actually very confused when I saw the vessels, uh, on some other conditions, uh, we call this hyperemia or it's where the, uh, new blood vessel formation within the area. I was actually under the impression that it was, uh, the new vessels meant new injury. Um, but one of the, one of the, uh, uh, doctors that I spoke that I spoke with actually, they said that these actually sometimes they're with, with old conditions. And since there's in the Achilles area, there's a fat pad in front of it. So there's a, an area where it's very vascular. So sometimes some of the vessels come out of this fatty area and they start diving into, you know, the, the Achilles. And, um, I don't know if there's a actual YouTube video up or anything on this, but there's a, there's actually can, there's a procedure called hydro dissection.

And I remember seeing one of the doctors, uh, showed me it, it, it happening. Like it looked like they, so they had an ultrasound on the Achilles and they saw these vessels and this wasn't this guy, but by the way, it was a patient I didn't know. Um, but it was, it was cool to see. You saw the ultrasound on one side and you see the vessels pumping the red and blue. And, and then they take this almost like a water pick and they get in there and just start slicing the surface between the Achilles and the fat pad area. And all of a sudden you see the the vessels just drop in their activity. Like you don't see them anymore because on ultrasound, you really see actually, I guess you don't necessarily see the vessels for the colors. You see its velocity or, or movement of fluid. So the velocity changed to nothing. So you didn't see any Doppler findings anymore.

But, um, anyways, he was, so this guy, when I, when I ultra set on him, that was almost like what I wanted to do with him. I almost want to recommend him to hydro, hydro dissection. Um, but either way, I mean, he, I wasn't managing him as a patient. I was just giving him some advice. So we spent majority of the time just kind of talking about like what his possibilities are, like what his mindset is, uh, about what he's tried already, how badly does he want to run? Like, why is he running? And so on. And so we kind of went through and I asked him first about, you know, how is, how do you feel like your gate is, you know, like, what, is there any gate corrections you can possibly make? Because he's a, he was a running store guy.

You know, like a lot of times they'll assess people with gate findings and, um, so on when they're fitting them for shoes. So I asked him, is there any, you know, gate abnormalities you think that would be beneficial to correcting this? And he said, he's like, you know what, I've had people say this to me and bring up the idea of gate and stuff. And, and he said, you know, I've been running for, you know, like 30, 40 years. Um, it's been a long time. By the way, the guy was about, I'd say 50, 55. Um, but he said, I've been running since high school and college. You know, and like, why is all the, all of a sudden now, why is a gate issue a big deal? You know? And, and I said, you know, like a lot of times, like it's, these are running just like many other sports, they're repetitive wear.

And if you're demanding too much on a tissue or a side, even in this case by proper gate mechanics, then they're eventually going to blow out. And he said, well, you know, like I've gotten this far, I've been running for this many years. How come all of a sudden it's an issue now? I said, look, I don't want to be devil's advocate with this, but I'll be straight with you, man. You know, like the, why is it only one side and not the other? Like, why is your left Achilles like an issue right now? And the other one's not, you have the same amount of mileage on it. You know, I'm sure if you're doing track workout, you're only going one direction around track.

Maybe you should try going around the other way, possibly, you know, to just to break up the amount of load you have on one leg. Um, but then he kind of went a little bit further and said, you know, he's like, yeah, I've been thinking about that too. So he told me back in college, he had issues with his left knee, his left hip, his left foot, you know, so it seemed like it was a consistent pattern going on. At least like, it seemed like there's, it was a left sided thing for him. And, you know, again, just playing along with devil's advocate, I just said, like, look, you know, like you've had, it seems like you've had issues on the left side for a long time.

Um, you know, I'm not going to assess your gait today. And I, I'm not sure if anyone's going to assess you further today or the coming week or whatever. But, you know, it's, it's something to consider that usually tissues don't always break down unless there's past injury on it, or there's a reason for it to be compromised, or you're forcing us to do something that's not really not intended to do. Um, and I know Achilles issues, you know, they go hand in hand with, uh, hip and trunk, um, uh, issues with functionality, strength, the range of motion, sometimes foot cave, uh, or pronation, they say would be, uh, accordingly defining as well.

Um, so I asked him if he, you know, has he, has he been doing rehab? And he said, yeah, I've been doing some like band work on the Achilles or, sorry, in the ankle. So he showed that he was doing like, you know, flaring the, actually for the medical people listening. So he's doing eversion, inversion, plantar flexion, dorsiflexion for all the patients listening or all the athletes listening. Um, he was kind of moving his foot in different or his ankle and did all the different ranges under with a resistance band, which is a good one to do, but that's an open chain or foot, not foot, not on ground exercise as well.

So he said, yeah, I was doing some balance work, some single legs stuff. Um, and then he did some core things as well as hip strengthening things. But so at the time, like when I examined him, like he wasn't running or anything like that. So like my interpretation is you have a lot of time, man, you got free time. You should be doing a bunch of stuff, you know? And I think that there's such a strong correlation of, of landing pattern and gait abnormalities with, um, trunk control, trunk endurance, um, hip or pelvis types of findings that, I mean, if I were him, I would probably, or I did tell him, I said, look, about three, four days a week.

I think you probably should be doing, you know, some core hip, single leg, double leg stuff, closed chain or foot on ground types of exercises if you can tolerate it. And the great thing with, you know, the, I think the, the, the point that he's at is, I mean, I asked him like, how often do you squat and deadlifts? And I know if you've listened to my other podcasts, you've, you've heard me talk about this stuff probably quite a few times, but, but realistically, like doing like strength moves like that. I mean, like say a set of squatting, like 10 reps or so you, I mean, there's, there's almost, there's not a ton of load on the Achilles.

It's not like we're doing box jumps or having to run a track workout. So the possibility of having him having a further injury, especially if you keep the load well under, you know, like 80%, one or max, I think you're perfectly fine. And it's going to be building up around the trunk and torso and legs and all the stuff that he's going to need to be stronger or need to work better if he's taking this much time off. So he did say he was doing some other cardio. He's been swimming and biking and stuff and he just didn't seem satisfied with it. And usually when I have runners come in or endurance athletes or, you know, someone that's not really not, it's not really forced by any means to, um, to compete.

And what I mean by forced to compete is like, so in college, like if you have a scholarship, there's a reason, there's a monetary reason for you to compete, you know, or you have a team that you're caring for and so on. So there's all these psychological reasons to keep going. But when you get beyond college, you're not, you're not making money for, for running or playing your sport. What drives you to do it? And I, I'll be honest with you. Like I've found people like some runners, actually there's, there was a, there was a great case that came in a few weeks ago that, um, it was very, it was very refreshing because she, uh, she was just very straight out with me.

So she was, she was running. She got hurt. She hurt her knee. She hurt her meniscus actually in her knee. And, uh, I said, why, you know, why are you, why are you running? Like, what's your thing? Why do you like that? And she's like, honestly, if you've been married for two years, I feel like I'm going to get fat. I don't want to, I don't want to get fat. I'm like, so are you open to different types of, uh, exercise or dieting stuff? So you don't get fat. So you're, uh, basically we're sort of rehabbing around this knee and then you go back to running if you want to, if not, I mean, we're still getting you to your goal.

And she's like, yeah, yeah, it's exactly what I want. So, um, this guy asked him, why are you, why are you running? And he, he said, so he loves running. You know, he just loves it. Like he does master track. He runs a four, 400 and 800. Um, so what I wanted to get to the bottom of is like, you know, is he doing it because he has had heart conditions in the past? Is he doing it so he can, like, I've actually had people say that the only reason they exercise is so they can enjoy drinking beer with friends. Um, so they want to make sure to control their weight and, uh, you know, control their lifestyle so they don't like binge on one way or another.

But this guy just really loved running for running. So I, I'm not going to tell him not to run and I don't want to steer anyone away from running or doing what they love. But we have to consider too, is it the right thing for the injury at the time? And so according to what I saw, at least on the ultrasound, I told him I'd really consider not at this point. Like I would really strongly advise not to. And if you wanted to test it, like, so he asked, he's like, so I'm here because I want to figure out if I should just go test it out in the track, just run some 400 to 800, just go about like 75%, uh, percent capacity, like well below, just kind of testing things out and getting strides in and so on.

And I said, you know, why do you want to do that now? Like what, have you, have you honestly done everything you think is merited to make it so you won't blow this thing out as soon as you step on the track? So we started listing some things off, you know, have you done, or I did. And I said, have you done, you know, ankle band work? And he said, yes. I said, did you do intrinsic foot muscle work or strengthen the small muscles of the foot? And he said, no, I've never done that before. I'm like, well, how many days of work were you doing core strength or, or, uh, hip strengthening stuff when you're, you know, down or doing rehab?

And he said, ah, maybe about one. I said, okay. I'm like, have you done, doing any hip stretching stuff? Well, no, I haven't. Okay. You're getting your cardio, cardio in other ways. Yeah, you are. Yeah, he was. So I said, realistically, I'm like, knowing what I know about Achilles issues and extremity or leg issues, I'm like, man, there's so many other things you can do to protect yourself from blowing this thing out. And, and like, from a responsible standpoint, you know, like, I think you should, you should do everything you possibly can to diminish your risk with these injuries. And I mean, if he's going to be running, I mean, like he can probably even go out and run, you know, three to four miles at, you know, conversation pace and be perfectly fine because the ground contact, uh, forces is much less with slower jogging.

But if he's trying to just blow around the track, then it's going to really be a much higher. So I just straight up with him. I said, look, I think there's a lot of things you can do prior to, you know, risking it and stepping on the track. And I know you really, really want to run, but would you be happy if he blew this thing out or if it didn't get better for the next year or so? Because I actually took him in the back, um, in a different room because during the study, when I saw that lady who had, uh, the four year old, uh, ankle injury and she had all these vessel formation and everything, I actually put it on a canvas print in my room because I like to show people.

So it was on one side, it showed her normal side and the abnormal side. And I said, you see the blatant difference between these, you know, like there's, there's stuff going on. And a lot of times in ultrasound, when you have a Doppler finding like that, it's, it's very, very indicative that this is a cause. This is, this is an active condition. Um, so anyways, I showed him this picture and I said, look, this is this lady. And I told him the story and I said, you are actually the second, like if you're a part of the study, you would have been the second most positive finding that I had with the entire study, I'm like, that's how serious looking your ankle looks.

So I'm like, you tell me like, you can, you can definitely step foot on the track. So do you, would you be happy if you blew it out? And he said, no. So, um, after that, I went and just kind of Q and A with him a little bit. And like, he asked like, Hey, my friend has a boot. Should I put a boot on it? And I just told him the pros and cons of immobilization on, on an ankle or like any areas that you lose strength about four times as fast as when you build it up. So I'm like, if you, if you're booting it, I'm like, you know, usually we would reserve that for things like, um, I mean, I would do, uh, ATFL tears in it or ligamentous tears, um, uh, fractures of cartilage within the talar dome area or like deep within the ankle.

These are reasons that you want to immobilize, but you don't want to mobilize too, too long. And, you know, they, they started actually with, with knee replacements. Uh, they, they have a continual motion machine and they found that people really respond better when you get more movement, if it's safe, if you can move it, move it. So I just told him with booting, like, I'm like, you're, look, you're three months into your injury at least. And who knows if this thing's longer, but probably your, your Achilles is probably fairly stable at this point. You know, like, I'm like, if you boot it, I probably want to go more than five days to a week, you know, but if you want to, if you want to take that route, just know that you're going to lose a little bit of strength and, um, you know, do everything you can in regards to, you know, if you're going to, if you're going to put the boot on, make sure the boot's on and you're not just dilly dallying with this type of, uh, you know, methodology with it.

So, but if you can try it, if you want to try it by all means, and especially if you have a, you know, a free boot, I think you can definitely try it. And I, I think people have to feel really good about their treatment plan. They have to, they have to know they've taken the necessary steps to take the next step forward and do whether it be the right thing or the, or a different thing to rehab it. In this case, if you wanted to do booting, he definitely could. Um, so then he asked about icing and I said, look, you know, icing is, um, I've seen some controversial things about icing and it's, it's been shown to decrease healing time in some people, but you know, there's, if we're trying to decrease inflammation in the area, like just consider like pain, pain is, is one of the five parts of inflammation.

Like, I'm like, if you want the area to heal and you want stuff being shuttled in there, like proteins and, you know, uh, growth factors and all that kind of stuff. Like you want, you want good things going in there. So it can repair it to like ice or anti-inflammatories will in theory decrease the whole inflammatory process, not just part of it, not just pain. So I'm like, you really got to ask yourself if you want to arrest that or not. So anyways, this is a, this was a really interesting case to me. And I thought I would share, um, because I think I really want to get down on the bottom. Like how badly does he want to run because I can recommend everything under the sun for this guy.

And I can recommend, you know, a bunch of rehab, a bunch of tissue work and so on. And, but realistically, if he's not, if I don't know his mindset, he won't comply and he won't, he won't follow through with a treatment plan. So you have to sometimes get deep down inside of them and just figure out what's the reason they're doing what they're doing or what's the reason why they'll be hesitant of doing a treatment plan or whatever it is. So, uh, he was a very nice guy though. I had a great, I had a great time talking with him. Um, but, uh, yeah. So if you guys have a question for me in the podcast too, um, just go onto the P2 Sports Care site.

Uh, right now it's actually under construction. So we're transitioning from one site to another. And currently there's a speak pipe voicemail button on the old site, but on the new site, I'm going to have it very visible. I don't know if it'll be in the center anymore or not, but basically just go through this thing and you click it and you don't have to have a phone or anything. You just talk directly to your computer, send it away. And then the most detailed ones, the most interesting ones that I think everyone's going to benefit from, I'll, I'll talk about. Um, but yeah, you can ask a general question.

Um, you can ask detailed ones and so on about yourself. But remember, um, just kind of the disclaimer on this is that I'm not really allowed to give one-on-one recommendations because I need to see people in person to be able to do that. That's just kind of healthcare law. Uh, I know most patients don't understand that, but we do have regulation on that because we're supposed to be given the right information. So this is very general and in theory that I try to stay with these things. So, um, yeah, thanks for listening guys. And, uh, I'll talk to you next time.