Beware of quick-fix remedies, including cortisone injections - Updated

Hi Gary
As promised ages ago the following is a blurb about my ankle injury.

Photo One: Permanent damage from loss of tissue to the Tibilais Posterior tendon caused by cortisone injection. She is compensating for loss of muscle function with overuse of other muscles which shows as an unusually contoured foot.



I originally contacted you back in early September of 2006 to get a second opinion about an ankle injury that had been an ongoing issue for me for close on a year. I first became aware of a problem whilst training for the Kepler Challenge last year (2005), it started out as niggling pain on the inner side of the left calf and I initially assumed it was my Achilles reacting to a running load that was heavier and faster than usual. I had been training with guys and as a result was pushing myself harder and faster and training runs were tending to become all out races. When easing back, reducing the load and rest did not seem to help I went to a local physio for advice.




Photo Two: The loss of tiabialis posterior function is compensated for by excessive use of the tibialis anterior (That is the tense-looking tendon on top of her foot)

The physio initially treated me for a strained soleus but then arranged an ultrasound which showed tendinitis in the Tibialis Posterior tendon just above the left ankle. The doctor who reviewed the ultra sound offered to "whack in some cortisone" there and then as a cure. The physio also recommended cortisone and referred me to a sports specialist who arranged for a cortisone injection under ultra sound. The specialist said that usually he recommends a two week break to let the cortisone work but that as I was training for an impending race to take two days rest before getting back into training.
The cortisone gave a fairly instant result - within a couple of days there was no sign of the injury left. All pain and swelling had disappeared. I went on to train and run not only the Kepler Race but several others over the ensuing months with seemingly no injury issues - BUT.. about six weeks after the injection I was left with an obvious hollow at the injection site and what was clearly a more seriously damaged tendon than I'd started out with.
I went back to the sports specialist who advised to take 3 months absolute rest from weight bearing exercise - which I did. But by the end of that rest period there were still obvious lumps along the tendon line below the ankle and the ankle bone itself was still nearly hidden by swelling. On returning to the sports specialist I was sent for a second ultra sound which showed that the synovial sheath of the tendon showed degeneration with 'ganglionic lumps' along it in an area below the ankle bone and the tendon above the ankle bone showed fluid and swelling with secondary scar tissue.
The original injury had been exacerbated by the cortisone injection and the consequences of it enabling me to run through the injury for too long.

The specialist arranged a referral to an orthopaedic surgeon. When I got to see the surgeon around 8 weeks later the Surgeon stated that surgery was the best solution but that it had to be my decision and should be done once I was sure that I could not run without it as being able to run after surgery was not guaranteed. The surgeon said that the operation would involve scraping down the tendon and if necessary - using a neighbouring tendon to help bear the load.
He advised and arranged for for orthotics to be made up and for me to go from neutral running shoes to Nike Gel Kayanos with the goal of starting to run on a treadmill - 3 x a week - building up by no more than 10% each week and starting from around 5 minutes at a time.

Not happy with trying to build up running on a still injured ankle I went to a different (recommended) physio and a massage therapist to see if I could avoid surgery and get some improvement. Regular massage treatment & acupuncture helped to a point that the ankle was visibly much less swollen and much of the scar tissue had been broken down. But the tendon was no longer doing the job it should be able to do and walking bare foot was uncomfortable. The sports specialist then made a call that he didn't think that the injury was is realistically going to improve enough on its own to allow me to run comfortably again so sent me back to the surgeon as he thought that the surgery track was the likely solution.

At that stage I felt as though I was just being passed from one specialist to the next. The physio who I had been making slow progress with suggested getting a second opinion before going to the drastic measure of surgery, and your name came up as a possible person to contact.
After an appointment with you and dutifully following your exercise instructions I feel that I've gained some strength and am feeling a lot more positive about running again than I was before talking to you.

Though the injury is by no means better, It has improved significantly since I was first sent to the surgeon and that improvement has come form strengthening exercised that you prescribed and from shear damn determination to do everything possible to strengthen and get back to at least being able to run with enjoyment again. In the process I have learnt that there is rarely a single solution to an injury and that you really need to educate yourself and question advice given even if it is from professionals who know more than you.

I am now at a point where I can run fairly comfortably for about 30 minutes (abet at a slower pace than I'd like) and where I can still see improvement week to week in strength and the visible look of the ankle. I've taken up mountain biking and spin classes to help get a good level of fitness back and have even partaken in a couple of bike races. Hard task is going to be holding of from getting out on the road running again to soon.
Debra

Feedback from the runner with the ankle pain

Here is some feedback from a runner with the ankle pain.

“I'm great... I've been back runnning for about 7 weeks...

“When you told me to start back , you will probably remember I still had the throbbing scenario - after that the ankle was giving me pain in the first few weeks of running. I've crept up slowly in kms and have had to go at a slower pace than I want ... but it's now not throbbing at all and only the very rare day do I feel familiar scary pains here and there.in the ankle... if that happens I get as much rest before the next session or swap sessions around.

So to answer your question yes your intervention did work for me, I was going backwards for many months (9 in total ) with the rehab exercises which I reckon were aggravating it more.

Before I ate healthily but now am using protein (just after a session which I never did before), calcium, minerals and flax will keep going and will keep the joint powder going for a good while yet.

Yes looked at the blog, and that is a great article, I hope it helps others make the right decision, all you need is a perceptive experienced advisor.You are the only person that I saw that wanted the entire background to my running habits and history.... and thank you ! “
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Gary Moller comments:
This very fit woman has made a remarkable return to running training. What she shows is the value of looking at the total person, including her health and exercise history, training programme, diet, physique and biomechanics - and let's not underplay the role of her determination to get back into running!

When attempting to understand how such injuries develop in the first place, it is essential to understand the constant balancing act that is going on inside the body between anabolism and catabolism. If an athlete is in a state of chronic catabolism, there is no way that any kind of medical treatment is going to "cure" her.

Although this dedicated runner has made a quick and remarkable recovery, healing and repair should be regarded as a slow and gradual process, taking several months, if not years to fully run their course. Too much therapy is on the basis of a 1/2 dozen visits and, if there is no cure, then more drastic action is recommended like surgery, or cortisone. Of course, these don't work and can leave the athlete with much worse problems over the longterm.

Central to modifying her training and diet and her doing some special exercises, is the moto "Body, heal thyself". This is a phrase all health professionals should constantly mutter away to themselves as a constant reminder that they never heal or cure - it is the patient's body that does that!
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If you have a chronic injury or illness that you are getting nowhere with fast, and if you are in Wellington, I run a private clinic in the central city. Get hold of me to arrange a consultation - I really do enjoy the challenge of working with people like you!

Stiff Big Toe (Hallux Rigidus) in active people - runners and other athletes

The most common site of arthritis in the foot is at the base of the big toe. This joint is called the metatarsophalangeal, or MTP joint. It's important because it has to bend every time you take a step. If the joint starts to stiffen, walking can become painful and difficult.

In the MTP joint, as in any joint, the ends of the bones are covered by a smooth articular cartilage. If wear-and-tear or injury damage the articular cartilage, the raw bone ends can rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The result is a stiff big toe, or hallux rigidus.

Hallux rigidus usually develops in adults between the ages of 30 and 60 years. No one knows why it appears in some people and not others. It may result from an injury to the toe that damages the articular cartilage or from differences in foot anatomy that increase stress on the joint.

Signs and symptoms

* Pain in the joint when you are active, especially as you push-off on the toes when you walk
* Swelling around the joint
* A bump, like a bunion or callus, that develops on the top of the foot
* Stiffness in the great toe and an inability to bend it up or down

Diagnosing the problem
If you find it difficult to bend your toe up and down or find that you are walking on the outside of your foot because of pain in the toe, see your doctor right away. Hallux rigidus is easier to treat when the condition is caught early. If you wait until you see a bony bump on the top of your foot, the bone spurs will have already developed and the condition will be more difficult to treat.

Your physician will examine your foot and look for evidence of bone spurs. He or she may move the toe around to see how much motion is possible without pain. X-rays will show the location and size of any bone spurs, as well as the degree of degeneration in the joint space and cartilage.

Nonoperative treatment options
Pain relievers and anti-inflammatory medications such as ibuprofen may help reduce the swelling and ease the pain. Applying ice packs or taking contrast baths (described below) may also help reduce inflammation and control symptoms for a short period of time. But they aren't enough to stop the condition from progressing. Wearing a shoe with a large toe box will reduce the pressure on the toe, and you will probably have to give up wearing high heels. Your doctor may recommend that you get a stiff-soled shoe with a rocker or roller bottom design and possibly even a steel shank or metal brace in the sole. This type of shoe supports the foot when you walk and reduces the amount of bend in the big toe.

A contrast bath uses alternating cold and hot water to reduce inflammation. You'll need two buckets, one with water as cold as you can tolerate and the other with water as warm as you can tolerate. Immerse your foot in the cold water for 30 seconds, then immediately place it in the hot water for 30 seconds. Continue to alternate between cold and hot for five minutes, ending in the cold water. You can do contrast baths up to three times a day. However, be careful to avoid extreme temperatures in the water, especially if your feet aren't very sensitive to heat or cold.
Source: American Academy of Orthopaedics
(This article then goes on to describe the surgical options)
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Gary Moller comments:
This article is pretty typical of the advice given for arthritic toe conditions. For the athlete, the advice is inadequate, does not get to the heart of the cause and does not offer lasting solutions.

Sore toe joints is a common complaint in active people. It can come about as the result of a joint sprain or dislocation, such as happens when kicking or when the foot is trampled by a sprigged boot. It can also happen as the result of excessive repetitive repetitive stepping back and forth such as when doing Tae-Bo fitness classes. Accidentally stubbing the toe on a piece of furniture is another painful cause.

Joints require movement to be healthy. Without movement, the joint tissues are poorly nourished and they may consequently degenerate, causing a painful arthritic condition. If there has been damage to joint ligaments, such from a dislocation, the scar repair that binds the healing joint shrinks over time. If this is not stretched and mobilised during the healing process, the joint may be bound painfully together. Scar tissue shrinks over time and must be stretched and softened to ensure there is the restoration of normal function.

Wearing shoes all the time can contribute to the development of a painful rigid toe by restricting the natural movements of the feet. Feet, including the toes, are designed to be flexed and extended all the time to be strong and healthy. Shoes are no good for the feet if worn all the time. Lack of natural movement lays the feet open to the development of arthritis.

If you hurt a toe
So long as it is not broken, immobilise it for no longer than about 2 days. Using the healthy toe on the other foot as your guide, gradually work within pain limits to restore normal movement over several days. This should include careful traction to gap the joints.

If you have developed a rigid arthritic toe
This is where the fun begins and where I come into action! Forget about the injections, ultrasound, ice and surgery: By far the most effective way to fix an arthritic toe in an athlete is manipulation without anaesthesia. This can be extremely painful for the affected person. One woman described the pain as being more intense than child birth!

The purpose of the manipulation is to gap the joint that is bound tightly together by scar and unhealthy fibrous tissue, to break up any restrictive adhesions and calcification and to get some circulation back into the joint tissues.

There is no need for pain relief or anti-inflammatories. It may be a good idea to take some glucosamine and chondroitin and MSM to aid the healing.

While this procedure is agonising, the result after just 3-4 sessions is dramatic pain relief and full resumption of normal activity. Over the years, the results have been 100%

Ongoing maintenance of recovery includes getting about daily barefoot. Running and walking on sand is best for keeping the feet strong and healthy.

Please read my other articles about this painful and disabling condition (hallux rigidus).

If you have a problem with a stiff and painful toe, contact me directly.

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I think I broke my ankle while out running - Part II

Well, I am back to careful jogging after having cracked the medial malleolus of my right ankle. I am even playing soccer with my son. Here are a couple of photos of my ankles 13 days post injury:

If you look closely, you will see that the ankle bone on the inner side of right ankle is noticeably thicker than the left hand side. This bone was fractured when I went over on the outside of my ankle while running off road (Refer earlier report here and compare photos). Some people think I have the boniest ankles in the business!

What is really important is the fact there has been no muscle wasting, there is no loss of ankle mobility and the ankle reflexes have been restored to pre-injury working order. If the ankle had been immobilised for this period of initial healing, there would have been a period of several weeks rehabilitation to restore normal strength and function.

Now, I am not suggesting for a moment that a person with a fractured ankle forgo with immobilisation and commence exercising, including soccer as part of their rehabilitation. However; I am using my case as an example of how a carefully managed "sports medicine" approach to injury management can bring about wonderful results. The fracture was not unstable and did not directly involve weight-bearing bones.

First of all, I ensured there was minimal swelling despite having to continue walking and jogging for an hour after the injury just to get home. I then determined what I could and could not do without stirring up the injury - how to remain active while the scarring and callousing knitted the damage securely enough to take the strain of this or that activity. I had the injury site massaged daily after about the first 36 hours. I took no pain medication, including anti-inflammatories which might interfere with the healing processes. The closest was some flax oil, bone broth and joint food to assist the joint and bone with healing. Long, hot Epsom Salt baths with a cool bottle of beer on the side were my pain management. I walked daily up and down steep hills for as long as the pain was bearable, steadily increasing the distances as the days passed. I practiced balancing exercises to strengthen the ankle muscles and to retrain the reflexes.

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Treating a sprained ankle

Dear Gary,
I have quite a nasty sprained ankle that happened whilst running (in the dark!) on Wenesday morning last week. I landed badly on some uneven ground and my foot went over and I felt intense pain and some bad pulling/tearing sensations on the outside of my ankle - either side of the bone. I managed to make it home, but the next day it was quite swollen, and has come down now but is still tender.

I can walk quite happily, but don't want to get back running too soon in case of more damage. How long do you think I should wait before beginning to run on it again? Should I have had any treatment on it, or will it just take time to heal? Do you forsee any long term problems - or are there some exercises that I could do to help strengthen it apart from just running? I would appreciate your advice, as I am really missing my runs at the moment!
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My reply:
I think you will be ready to start running now. Ankle pain can last for months but is no reason not to get out there.

Read this carefully: http://freerangers.blogspot.com/2006/05/pouring-cold-water-on-ice-therapy-for.html

Start on soft ground and gradually build your speed and duration. You might like to do some aquajogging as well, if you are inclined.

Another measure is to purchase some Nutra-Life Joint and Cartilage Repair and take it regularly for as long as there is any discomfort.



Go to a sandy beach and power walk up and down the soft dunes barefoot and then briskly wade in the cold shallows for 15-20 minutes.

Finally, practice balancing on each foot, eventually with eyes closed. This restores the reflexes to the ankle as well as strength.

I hope that this helps. Let me know how it goes, thanks.