Sports Medicine Specialist at UC San Diego, Kenneth Taylor, MD talks about overuse injuries.
Interview conducted by Ivanhoe Broadcast News in October 2023.
Do you see a lot of overuse injuries?
Taylor: Pretty much every day.
Can you go into detail?
Taylor: In some ways, it’s a good thing because we have a very active population here in San Diego. And Ohio in particular, we have a lot of athletes, weekend warriors, and people who put a lot of value in fitness, which is great for your health. But unfortunately, many of us are over-achieving type A personality folks. We think that more is always better and sometimes more is a little too much. People need to pull back a little bit. We see a lot of acute injuries, but we also see these chronic overuse injuries.
Of the chronic overuse, what would those be with, are those like tend?
Taylor: Just about any tendinitis. Tendinitis typically is just the first few weeks of an overuse injury of the tendon. Then what happens most of the time is that it is, which is the inflammation tends to start to go away, and then the body just ignores it. What happens is if you think of tendons as like ropes, you can buy a brand-new rope and it’s all pristine and perfect and there’s no frayed ends. Then with time and repetition, microtrauma, and repetitive use, that perfectly looking brand-new rope starts to get a little frayed and it’s got split ends. Instead of being nice linear fibers that are all pulling in the same direction as they’re supposed to, they start to get mixed up and they lose some of their bio-mechanical efficiency. You get friction, swelling, degeneration, and irregularities, and you even get cysts and swelling in those tendons, so it can become quite painful. But because it wasn’t an acute injury, maybe there wasn’t a sudden impact or traumatic event. There’s not necessarily an acute tear. There may not be any bleeding and the swelling may be just very minimal. The body just doesn’t mount very much of a healing response. If you get sliced by a knife, it swells, there’s bleeding, growth factors, platelets, everything comes in to stop the bleeding and then start the repair process. But what happens with a lot of these repetitive overuse injuries, is that there was never that much of an initial response to the injury. It’s just at such a microscopic level, that you just can see continued injury and insult to injury and more insult to injury. But there’s never really, the body just doesn’t know what to do with this. It causes a lot of pain. It can cause some weakness. It can certainly impair function. But because there was no overwhelming healing response by the body, just gets ignored and oftentimes gets worse and worse and you can rest it. Usually, if you rest it, the pain reduces or goes away. But when you rest something, it gets a little weaker. If you like to hike or walk or run or whatever it is that you enjoy, you rest it, the pain gets better, maybe goes away. As soon as you try to do that activity again, it comes right back. The tendon or the overuse injury hasn’t healed. You get into this vicious cycle of it used to be maybe 10 miles into a run. Your Achilles tendons start to bother you, so you back off and rest it. Then you try to go back to running. Now it’s only, it kicks out. It starts to hurt in five miles and then two miles, and then you can’t even run anymore. Then at some point hiking starts to bother you and that never used to.
So, what you do about it?
Ken Taylor: There’s a downward vicious cycle. Like most things in medicine, we try to do the safer conservative measures. We don’t go straight to injections and surgeries and things like that to start with. Many of these overuse injuries respond to exercise. If we think of running as thousands of cycles of muscle contractions and tendons getting tugged and bones getting tugged, there are thousands of cycles. It’s a small load, but it’s translated over a long period. Those thousands of cycles cause a lot of friction and a lot of overuse. Maybe there’s not that much of a healing response to make that tendon stronger for the long haul. It gets ignored, it breaks down, and sometimes you must reverse course and instead of logging thousands of repetitions, you need to up the resistance. You might need to start doing some weight training. An achilles, for example, will back off or try to reduce the running, to reduce the pain, and then work a little bit more on strength training. There are different types of strength training we do, like when you lift a weight, you’re doing a concentric contraction. And when you’re slowly lowering that in weight room terms, we would call that a negative, but in medical terms, we call that an eccentric contraction. There’s a lot of good evidence that shows that eccentric muscle training has a relatively high load. In other words, you shouldn’t be able to do 1,000 or even 100 times. If it’s heavy enough or strong enough resistance, you can only do it maybe 10, 15 max 20 times. That’s a lot of work for that muscle, so it’s going to create an overload situation in the muscle. The muscle gets the stimulus that it needs to build up and get stronger. As the muscle builds up and gets stronger and hypertrophies, the same signal starts to go to that tendon. The tendon does a remodel basically. It starts to remodel, and it breaks down some of its weak fibers and tries to build them up with stronger fibers. That’s what happens when things like physical therapy and resistance training. They fix a lot of these tendon problems but.
What if it doesn’t?
Taylor: Unfortunately, as we age, those healing properties tend to slow down. It takes longer and it’s harder, and sometimes it’s incomplete, or sometimes the pain is so severe that you can’t do the exercises to get it better. You’re stuck in a bad spot where it hurts so much, you can’t exercise. You do nothing and it just never heals or repairs, and it gets to the point where just basic daily living. You’re living with pain and it’s just you can’t do enough load to get it better. That’s when we start thinking of other things outside of the conservative rehab or strength training modalities, and we start looking at certain types of injectables. There are several different injectables we do and probably in particular, we’re often starting with something called platelet-rich plasma, which I think most people know about, also known as PRP. We do it all the time. I’ve been doing it for quite a few years, we draw your blood, spin it down, process it, and we take out the plasma that’s very rich in platelets and so there’s a lot of growth factors. We take your good stuff and inject it in high concentrations into the bad parts of the tendon. We’re recreating an acute injury. Had you had an acute tear or a muscle tear that involves a lot of bleeding, and you get a lot of platelets, and you get a lot of growth factors that naturally would go in that space? But these chronic overuse injuries never happen. It’s like we’re fooling the body into thinking this is a chronic injury. We’re putting all the basic building blocks of tendon and soft tissue repair into a diseased location or a degenerative tendon. Oftentimes that works and it helps that tendon repair. Unfortunately, it doesn’t work all the time.
It is that where we get to?
Taylor: That’s where we get to percutaneous ultrasonic tenotomy.
And what is that?
Taylor: Or PUT. Basically, what we do is we use ultrasound like a diagnostic ultrasound which delivers painless sound waves into any soft tissue structure. We can get good high-resolution anatomy of what that achilles tendon, looks like. We can scan that, and we can see what the normal parts of the tendon are, and what’s the abnormal parts, or the most diseased, or degenerative parts of that tendon. We can find the most diseased part where there are tangles and irregularities, and it’s usually exactly where the patient’s pain is. It’s swollen, it’s irregular looking, it’s a diseased tendon. We can identify the diseased tendon, and then through a tiny incision, a couple of millimeters, we can then take this device, it’s a tenotomy device. What anatomy means, it’s either cutting or modifying an abnormal tendon. It’s like what they do in surgery, but it’s done through tiny little holes, and using ultrasound we can very eloquently see this needle. We can direct the needle into the abnormal parts of the tendon, and we do so like a rope. If you take a needle and you’re sticking it in between the fibers of the rope, it’s not going to cause too much damage. But if you get too hard parts, or calcified, or irregular parts, or scar tissue, it’s going to break those areas up preferentially. But it’s going to spare the nice normal fibers. With the Tenex device or the percutaneous ultrasound-guided tenotomy device, we’re taking this needle and we’re sticking it into the diseased part of the tendon. Through repetition, we’re inserting it into the diseased areas and it’s breaking up the scar tissue, which is a very good thing. It’s removing parts of the diseased and scarred tendon. There’s irrigation that goes through there. There’s saline that’s circulating in and out, so that’s helping to get rid of the badly scarred, calcified abnormal tendon. It’s essentially sparing the normal fibers. You’re doing it in a certain fashion. You’re sparing normal fibers; you’re breaking up scar tissue. Instead of having to cut something out and suture it back together again, it essentially is doing it safely. It allows the body then to come in and finish the job. The body essentially comes in, it finishes the job. The beauty of that is it’s through a tiny little incision. Usually, there’s a couple of weeks of downtime. For a runner, we often have them back jogging and running in six weeks. Which is hugely transformative. If you were to have surgery on that, where they cut out the disease portion of the tendon, they usually must detach it from the bone, then they must insert it back into the bone. Well, that’s analogous to a complete Achilles tendon rupture. Those patients often have six, nine, 12 months of recovery. Whereas most of our patients are returning to a level at or higher than they were before the procedure at two or three.
Are they pain free?
Taylor: Not everybody. It does take a while, and I do want to emphasize that the device doesn’t necessarily do everything all by itself. We have great results where I’ll say patients, put in minimal effort and still get significant improvement. But my best patients are often the athletic motivated patients who, for example, qualified for the Boston Marathon. Now they want to run it. Those patients help because training for a marathon takes six months.
Is it the same as pickleball?
Taylor: No, but we do see a lot of pickleball entries. Pickleball is keeping me busy as well. But for a novice runner to run a marathon, you want to count on about six months to train and run that marathon. In this case that I did recently, a few years ago, she was an accomplished marathon runner. She’s an accomplished marathon runner, and unfortunately developed a severe Achilles tendinopathy, Achilles tenonitis in other words. There are a couple of different flavors to Achilles tendonitis. The common one occurs in the middle part. It generally does well, rarely needs surgery, and occasionally needs PRP, or the PUT, the tonomy that I do. But when you develop it at its insertion, which is right on the heel bone, right on the calcaneus, it develops a huge bump. It’s swollen, it’s exquisitely painful. It has a much lower success rate, with just conservative measures in physical therapy, and a higher rate of patients eventually needing some surgery or tenotomy type of procedure to get them better. That’s exactly what happened in this case. The beauty of this case is it’s been several years since we performed it. Not only did she do the Boston Marathon, but she also did incredibly well and had an amazing result. But I had the benefit of seeing her a year and even two years later, and her tendon was so inflamed, swollen, and painful that you could see it from across the room. It was red and swollen, and within a few months of doing the procedure, it looked better. When I saw it for a year, it looked pretty much normal. The last time I looked at it, it was normal. Not just on visual inspection but on physical exam, and then to look at it with ultrasound, so like looking at it with an MRI, to see a tendon that was so severely damaged, disrupted, disoriented, and degenerative. To see it look normal again in such a short period in a marathon runner, I think it is amazing.
When you take away from an athlete like that, you take away their sport, you take away their race. It changes their life.
Taylor: It’s depressing. It affects your mental health, which can affect your physical well-being. It all goes together.
Who’s not a good candidate?
Taylor: I think most patients are relatively good candidates. I’ve done diabetics, I’ve done older patients in their ’70s, pushing eight. Patients who are morbidly obese, have diabetes or infection risk, or are at risk of deep venous thrombosis on blood thinners, and are not particularly physically active and are incredibly deconditioned. That’s a challenge for anyone, but I will say.
On behalf of America?
Taylor: Hopefully that’s improving. But I will say those patients, surgeons usually avoid, and they say, I’m sorry, but I think your infection risk or your risk of developing a blood clot, or a serious medical condition from this operation is too high to do it. I don’t have much to offer you. I have taken those patients and have seen improvements. Are they running marathons, eight months later? No. But they have different goals. Some of them just want to go to Europe and walk around, be active, and enjoy vacations or return to hiking. It can be done. But definitely, as we age and as we accumulate more diseases our healing capacity declines, and our risk of infection or complications goes out. The benefits of just about anything tend to decline. I will say I haven’t had any complications with the procedure. There was a recent review that examined 34 patients who had exactly what I just described on their Achilles tendon. Thirty-four patients’ follow-up was about four years, which is a pretty long time. Out of 34 patients, there was one minor complication, and it was a possible minor skin infection that they applied a topical antibiotic to. There’s irritation from the needle going in and out of the insertion.
Are they susceptible for a cup to come back?
Taylor: I think anyone is susceptible. If you have a normal tendon and you can still get bad tendinopathy, then if you have a diseased tendon. I take care of Ironman triathletes and I take care of ultra-endurance athletes. I do find that some of the most horrific-looking tendons that even I think are ever going to heal. I have seen several of those patients either with ultrasound-guided tenotomy, with PRP, or with the right rehab. I have seen some of those tendons return to pretty much normal and have those patients return to triathlons and other things. I think in the world of tendinopathy, it’s certainly possible. Joints are a little harder. If you develop arthritis, we’ve got a lot of great treatments, but we’re not necessarily fixing it or returning it to its normal state. But I can see many of these tendons returning to a relatively normal state and a return to their previous level of athleticism and activity. I think some of these things that we can do now, are minimally invasive. If you compare cost, if you compare the surgical cost to the percutaneous tenotomies, it’s a fraction of the cost.
Can you be specific?
Ken Taylor: I think one study looked at costs upwards of around $10,000 for a typical surgery for this. Somewhere around 2000 or less. I do it in my office. There’s no general anesthesia. Essentially, they come in, I numb the area up well. Probably from the time they sit on the exam table to the time they leave, about an hour. The actual procedure itself probably takes about 10-15, to 20 minutes. It’s quick. It’s the prep time and sterilization, and the diagnostics, and everything that we do in between. The fact that we can do this in the office, with no general anesthesia, no sedation whatsoever, and most patients do fine with Tylenol afterward, which is pretty good.
END OF INTERVIEW
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