Ankle tendon pain

April 20th, 2012

Let's talk about ankles.

Lots of people complain about "ankle tendonitis", but what does this really mean? If the pain is in the back of the ankle, just above the heel, then you have a problem with your achilles tendon. If it's on the outside of the foot, running up the ankle, then you're looking at some kind of peroneal tendon pain. And if it's on the inside, running from the instep, under the ankle bone and up the leg a bit, then it's probably a posterior tibial problem.

Of course, calling any of these conditions "tendonitis" also might not be accurate. If you sprained your ankle and then developed some tendon pain, yes, you likely have short-term inflammation and need to do things like icing and taking aspirin to help combat it. But if you've had the pain for more than a couple of weeks, and it seems to be gradually getting worse without any kind of traumatic injury, then it's much more likely that you have ankle tendonosis.

If you look at the top right of this blog, you'll see a tendon/fascia test that you can take to determine which one you have. It's free and will only take a minute – literally. There isn't even an opt-in, so go ahead and do it now. The results may just change the way you think about your ankle tendon pain.

Peroneus brevis and peroneus longus tendonitis

February 25th, 2012

If you order Target Plantar Fasciitis and Posterior Tibial Tendonitis, you'll see that it comes with a video. The exercises I cover in both are for the plantar fascia, the achilles tendon, and the posterior tibialis tendon (or post tibial tendon). One thing that wasn't included was a what to do for the peroneal tendons (which attach to the peroneus brevis and peroneus longus muscles), which are located on the outside of the foot, opposite from the post tibial tendon.

You don't hear about it a lot, not like the Achilles tendon problems, but the fact is that quite a few people fall prey to peroneal tendon pain every year. And it can be really difficult to rehab, since it's smaller and more delicate than the other major tendons in the ankle and foot. So not including the peroneus sisters was an oversight on my part, and I recently received an email from a somewhat dissatisfied customer who suffers from peroneal tendon pain. In order to make things right with him, I have just finished a video that will be available to anyone who purchases Target Plantar Fasciitis and Posterior Tibial Tendonitis (from this website; the videos are NOT included in the Kindle version of the book) starting today. And for anyone who has bought it in the past and wants to see the new exercise, just send me an email at the address listed in the book and I'll hook you up.

Along the same lines, if there's something else that you'd like to see in the book, make a comment here and let me know.

Alex

Keeping it real – alkalinity and tendon/fascia pain

February 14th, 2012

I've been involved in the health and fitness industry for something over 30 years now, and no one can say that I don't appreciate the benefits that such a lifestyle confers. But if there's one thing that makes me roll my eyes about the industry, it's the exaggerated, unfounded claims that come with the territory.

I'm not just talking about bodybuilder protein shakes ("Put 7,423 calories of PURE ENERGY into your body! Supermaxidynamize it! Gain slabs of muscle in only five short minutes!!!"), although the supplement industry's claims are as outlandish as any. And I'm not just talking about the claims that various physical disciplines make either - although some of them would put Joe Weider to shame. (I read one book on Pilates that actually seemed to suggest the exercises helped to immunize people against the 1918 Spanish Flu epidemic.) No, the problem is everywhere. And remedies for tendon pain is no exception.

The specific point I want to talk about today has to do with one's diet, and how alkaline it is. Recently I've seen some discussion--and even some articles--about how people have supposedly cured themselves of long-term tendon pain by changing up their diet to make it less acidic and more alkaline. The most generally recommended way to do this by eating more in the way of vegetables and less in the way of meat, especially red meat.

I fully agree that too much acidity in the body can make it easy for inflammation to occur, and as we all know, tendonitis/fasciitis are conditions of inflammation. But thinking that your diet alone is going to determine whether or not you get (or can cure) some sort of ~itis is sort of like thinking that replacing your tires is all you need to get you into the next town. Certainly, if your tires are old and worn it would be a good idea to get some new ones. But most people are going to need some other stuff as well...like some gas in the tank...and a battery under the hood.

Another point is that long-term tendon or fascia pain usually isn't an ~itis at all, but an ~osis. Tendonosis/fasciosis means degeneration of the tissue itself, not inflammation, and you can eat all the vegetables you like but it won't have any effect on the collagen fibers that make up both of these structures.

Nutrition experts tend to see everything in terms of diet, and exercise folks look at everything through the lens of movement. But this overloading of one or another facet of health obscures the truth. And the truth is this: a combined approach is the best, surest, and more complete way to eliminate persistent tendon or fascia pain.

Cortisone shots and plantar fasciitis

November 5th, 2011

Thinking about getting a cortisone shot for that plantar fascia pain? You might want to think again.

I was searching around in the PubMed archives (yes, I do this for fun) and came across the following abstract. I've been preaching against cortisone shots for a long time, but this study really made me shake my head. From the abstract:

From 1992 to 1995, 765 patients with a clinical diagnosis of plantar fasciitis were evaluated by one of the authors. Fifty-one patients were diagnosed with plantar fascia rupture, and 44 of these ruptures were associated with corticosteroid injection.

Wow. So of the people who actually had a rupture, over 85% were associated with some kind of corticosteroid injection. (There are a lot of different types of corticosteroids, so not all of these may have been cortisone. But since all of the options are chemically similar, they might as well have been.) This means that there's a very good chance that if those patients hadn't been injected, the overall rate of plantar fascia tearing might have dropped from 6.7% to slightly over 1%. In other words, going from an uncomfortable but treatable condition to a full-blown rupture (i.e., now you need surgery) was more than six times as likely to happen with a shot than without one.

If that right there isn't enough to convince you, read on:

In most cases the original heel pain was relieved by rupture. However, these patients subsequently developed new problems including longitudinal arch strain, lateral and dorsal midfoot strain, lateral plantar nerve dysfunction, stress fracture, hammertoe deformity, swelling, and/or antalgia.

Okay, so you get pain relief from your plantar fasciitis...but then you develop a whole host of other problems. And if you don't know what all the medical conditions above are, let me just say that a lot of them are a lot worse than plantar fasciitis.

At an average 27-month follow-up, 50% had good/excellent scores and 50% had fair/poor scores. Recovery time was varied. Ten feet were asymptomatic by 6 months post rupture, four feet by 12 months post rupture, and 26 feet remained symptomatic 1 year post rupture. Our findings demonstrate that plantar fascia rupture after corticosteroid injection may result in long-term sequelae that are difficult to resolve.

So your recovery chances are 50/50. And these academic researchers, who don't have any particular ax to grind when it comes to one therapy or another (the study in question can be found here if you're interested), end by saying that corticosteroid shots are basically a bad idea because they can cause worse conditions than the one they were intended to heal.

Yet, as we all know, doctors still like to prescribe them. It just doesn't add up.

Before you try something that has been scientifically shown NOT to help, doesn't it make sense to try something that's been scientifically shown TO help? Especially if that something is cheaper? The techniques in my book have that scientific support (not to mention a whole host of real-world testimonials), but before you decide to order it I encourage you to take a free, one-minute test to see if they are right for your condition. No one therapy is right for everyone, and you want to make sure that something is a good fit for your particular condition before you spend any money.

A short discussion about “pattern overload”

October 5th, 2011

I'd like to talk a little bit about pattern overload today.

Fundamentally, pattern overload happens when too many repetitions of a given motion or exercise are performed. You don't necessarily have to be using a lot of weight to incur pattern overload; your own bodyweight can be more than adequate…as can a one-pound dumbbell if the number of repetitions is high enough. Even typing can become a problem if you fail to alter your hand, wrist, chair and/or keyboard position on a regular basis.

Generally speaking, pattern overload isn't too much of an issue because even with high-rep activities like running or swimming, each time your foot hits the ground or your hand slices through the water, your body is going to use a slightly changed "groove" when executing the movement. A highly trained athlete might be performing in more or less exactly the same groove for a time, but in the long run, as you begin to tire, your groove will begin to become looser and although this means that your efficiency of movement will degenerate, it's one way that the body tries to stop itself from incurring an injury.

However, some types of exercise can be relatively worse for pattern overload than others. And this can create discomfort in your tendons and fascia. One example would be exercising on gym machines to an excessive degree. People who work out using free weights have a significantly lower rate of pattern overload than those who work only on machines. The reason? When you're working with a barbell or dumbbell the weight moves in accordance with your body, but when you're exercising on a machine your body moves along the machine's predetermined and fixed weight-track. Even Smith machines, which incorporate a minor level of flexibility, are much more limiting and permit less natural "body adjustment" as you go through your sets than free-weight barbells and dumbbells.

Then, on the other end of the spectrum, there is Crossfit. It's not that I disapprove of Crossfit in and of itself. I think that the essential idea of Crossfit - do something different each day, and keep good track of your rest times - has a lot of merit, and there's no doubt that the training is stimulating and fun. But there are some drawbacks as well, particularly when you view Crossfit in relation to tendon injuries.

At base, a Crossfit workout involves choosing two or three exercises for distaff bodyparts, and then doing a lot of those exercises using a predetermined weight for a set time. The down time between sets is normally about ten seconds, and you rotate between exercises. As an example, one of the videos on the website shows three women doing bodyweight squats, then pull-ups/presses on gymnastic rings, then hang cleans with a barbell.

If you simply do too much of a movement, even if that movement is something totally "free", like swimming, you can acquire tendon and fascia issues if you exercise so much that the amount exceeds your body's capacity to recover. And this is where I have a problem with Crossfit. Yes, it's true that on their site they pay a lot of lip service to not doing too much, but the reality is that they use technically complex movements (like cleans) and push to the point where correct form totally breaks down. It's not the greatest idea for younger athletes, and for older ones it's an almost sure-fire recipe for injury.

Naturally, you need to push yourself to some extent if you would like to make your body better. But there is a question of degree. Without getting into a long discussion about exercise theory, the bottom line is this: the idea is to provide enough stimulation to create an adaptation response, but not so much that it becomes too difficult to recover from the workout. As the great Lee Haney said, "Stimulate, don't annihilate." All too often, Crossfit crosses that boundary.

So if you're suffering from fascia or tendon pain and have an exercise program (or doing some form of work) that incorporates too much pattern overload -- either through limited and unnatural movement or by simply having too much volume -- think about ways that will allow you to reduce or get around the problem. (You can take the free test on this page to see what sort of pain it really is.) You don't have to stop exercising, but you will almost certainly be better off if you find ways to change up your routine a bit.

Another great testimonial

September 22nd, 2011

This is a testimonial that I received on my other site, Target Tendonitis. Although Bobbi wasn't suffering from foot or ankle tendon pain, the techniques that she used are completely transferable and effective for the plantar fascia, and Achilles and posterior tibial tendons.

Dear Alex,

Thanks for checking in. Since my last email we've been traveling. You're entitled to some much deserved kudos!!

I feel I made tremendous progress, despite the "pep talk" (not!) the ortho gave me when I told him I was going to follow your protocol. I started with virtually no range of motion and tremendous pain in the elbow & shoulder to full range of motion and completely pain free for normal day to day activity in two weeks. I haven't started working out yet. When we get home I'll test it out on some light weights. Of course, I'm a bit nervous. I am a little confused to what my new regime will be. I do enjoy cross fit and wish my gym environment and trainer would be more supportive of what I need to do to modify.

Now, that I understand the idea of healing and maintaining tendon health, I'm excited to work on other areas (knees, back). Although, I am confused about how to target the back...

When we get home, there are many people I'm looking forward to recommending your book. I've seen a couple of msg boards out their full of people who could use your help. It's quite sad to realize how many people have really been suffering for a long time. I won't give away the secret but will definitely send them in your direction.

Thanks so much! Besides the healing, you've also provided me w/a tremendous amount of empowerment.

Sincerely,
Bobbi Casellas

There really isn't much to add here, except to point out how much more positive your outlook can be once you discover how to take control of your own tendon health. Bobbi is a 42-year-old weight trainer, crossfitter and generally very active. Congratulations to her for taking matters into her own hands and deciding to try something new--despite the advice of her orthopedist!

A New Testimonial for Healing Achilles Tendonitis

August 16th, 2011

I received the following testimonial the other day:

Dear Alex:

The book has been very beneficial... I have suffered from stubborn tendinosis three times. The first two ones were elbow tendinosis. I simply did too many pullups. These were not mere "tendinitis" . I aggravated the tendinitis because I didn`t rest enough. The point is I felt it in the morning only, but every morning was worse. So I had to quit pulling for months-well, more than a year-till I decided to perform [the recommended exercise].
I am currently curing from another one in my Achilles tendon. Now I´m better, but I had to stop running from last November to June. It was when I bought your book that I began doing [the recommended exercise], which improved my Achilles a lot.

To summarize : this stuff works and is very practical and easy to implement.

Thanks a lot, man. Tendinopathies really suck, and your book can help many people.

Santiago Ces Garcia

Kudos are due for Santiago, who decided to take control of his own recovery from both elbow and Achilles tendonosis. Congratulations!

The same techniques that helped him get back to working out and running can also help you if you might have plantar fasciitis or posterior tibial tendonitis. If you have either of these conditions, take a minute (really -- less than ONE minute) to take the test that will tell you whether the techniques contained in my book will help or not. The test is free, there's absolutely no opt-in or anything like that, and it might just change your life.

Fascia degeneration

August 2nd, 2011

I got a really interesting question a few days back from someone who saw one of my videos. He asked: "How can there be a quick recovery for tendonosis, which is tendon degeneration, if it takes collagen (what tendons are made of) 100 days on average to regenerate?" This question was about tendons, but it applies equally well to fascia, since fascia are made up of collagen as well.

This question is great. I love it when someone asks about a topic in an informed and constructive manner. First of all, you have to remember that "degeneration" doesn't always equate to "destruction". Degeneration in the context of tendonosis (or fasciosis) can mean several things, one of which is the destruction of the collagen fibers. This is sometimes seen with Levaquin patients, and in those cases recovery normally does take several months, if it happens at all. But most of the time it simply implies a degeneration in function or ease of movement rather than actual damage to the collagen fibers themselves.

What happens is this: in much the same way that adhesions affect muscle tissue, tendons and fascia that are affected by tendonosis or fasciosis develop points or sections along the fibers that begin to bind together. With skeletal muscle fibers, the mechanism is pretty clearly understood: tiny fibers are grouped into bundles to create larger fibers, which are in turn grouped into still larger bundles, until you have a three-tier structure.

Muscle and tendon structure

These bundles slide along each other at every level when a muscle is functioning normally, but when adhesions develop they stick at certain points, which then causes pain during movement. A competent physical therapist can ordinarily find these areas just by feeling along the muscle. Then s/he can use finger pressure to break up the adhesions and get the muscle back into proper working order.

With tendons and fascia, the situation isn't as clear. One factor is that collagen doesn't contract…but it does stretch and have some tensile strength. Perhaps because of this, simple finger pressure or massage is typically not enough to break up the adhesions that form. This is partly because collagen isn't as flexible as muscle fiber, and partly because the location of the tendon or fascia itself can be harder to get at. Also, since tendon and fascia fibers don't slide along each other the way muscle fibers do, the theory is that the collagen fibers somehow get intertwined, developing what could be pictured as "crosshatches" of collagen. A method of re-aligning the fibers, so that they no longer interfere with each other, is necessary.

Some type of "collagen comb" that could go through the fibers and straighten them out would be ideal. But since that's not possible, the next best thing is specialized exercises that, over the course of a couple of weeks, will generally accomplish the same effect. You don't need to go to a lot of expense on this, either. There is a large body of research that indicates that simple collagen strengthening and rehabilitation exercises done at home can be just as effective as platelet-rich plasma, cortisone shots and other such "cutting-edge" treatments.

Levaquin and fasciitis

June 23rd, 2011

Levaquin. It's a drug that can completely destroy your body's connective tissue, and I am encountering more and more people who have taken it at some point in the past and now have what seems to be irreparable tendon and fascia damage. Tendon problems get the most press, but it's a fact that the fascia are often affected as well. I intend to write a more in-depth post about this topic soon, but for now, if you are suffering from tendon or fascia pain as a result of taking Levaquin, well... the outlook unfortunately isn't very good.

One technique might have some potential: lowering the intensity of the reparative exercises that are given in my book. The usual prescription is to exercise while trying for about a 2-3 on a scale of 0-10, 0 being no pain at all, but people who have taken Levaquin seem to do better if they just aim for a "1", at least at the beginning of therapy. Given proper nutrition and exercise, and enough time, you may be able to strengthen your fascia and tendons even if they've been affected by this drug...but it's going to take a while and you're probably going to have to start out from a lower threshold than people who have not had this particular type of debilitation.

Say goodbye to the Food Pyramid

June 3rd, 2011

In a long overdue move, the United States Department of Agriculture (USDA) has gotten rid of the famous Food Pyramid that for close to two decades was supposed to tell you how to eat. The new symbol is a plate-and-cup that will hopefully be easier to understand.

Michelle Obama, Agriculture Secretary Tom Vilsack and Surgeon General Regina Benjamin got together to announce the new paradigm, but the message seemed to be a little contradictory. According to Ms. Obama, parents "don't have time" to measure out portions of food...yet, according to Dr. Robert Post, Deputy Director of the USDA Center for Nutrition Policy, “We know that with proper planning, you can get enough protein" from a vegan diet.

Hmmm. I can tell you from personal experience that, once you have the scale, it takes about ten seconds to measure out a portion of anything. On the other hand, I know very few vegans who actually (a) combine plant proteins properly on a regular basis and (b) get enough overall protein into their bodies (which is probably why so many of them start looking gaunt and eventually go back to eating animal sources). I have nothing against any particular diet plan, so long as it's healthy, but let's be clear about the realities of eating. Weighing food takes almost no time at all, and there is no better way of coming to grips with the reality of what you're putting into your mouth--it's just that it's a bit of a hassle.

Anyway, time will tell if this new plate-and-cup idea takes hold. Meanwhile, if you have long-term tendon or fascia problems in your feet, here are some food-based issues to consider:

If you are overweight, an obvious first thing to look at is losing the excess poundage.
If you are underweight, are you eating enough good fats?
For any American male, do you consume a large amount of red meat versus little in the way of fish and/or nuts?

Any or all of these can be (and probably are) contributing factors to your pain. Fixing them is one step toward having healthy tendons and fascia and preventing recurrences of tendonitis/fasciitis. For more information about nutrition and supplementation as they relate to having healthy tendons/fascia, check out my book Target Plantar Fasciitis and Posterior Tibial Tendonitis.