If you’ve ever had problems with hamstring, rotator-cuff, tennis elbow or other tendon injuries (like I do — sigh), here’s some news on the latest treatments …
In its entirety (however, the bold is snoety’s) from The New York Times, One Injured Hamstring; a String of Treatments,* Gina Kolata reporting: …
“Last April, at a meeting of the American Medical Society for Sports Medicine, three experts in tendon injuries sat on a stage and talked about their preferred treatments.
One said that the best treatment was to inject small amounts of a patient’s own blood into the injured tendon.
Another said that the best method was to concentrate the platelets of the patient’s blood and then inject the concentration, a substance known as platelet rich plasma.
The third advocated a form of muscle movement called eccentric contractions; that is, contracting a muscle while an external force is trying to lengthen it. For example, an eccentric contraction exercise for the bicep is to bend your elbow and bring a weight to your shoulder, then lower the weight in a biceps curl.
The three doctors had to agree to disagree. No one had the evidence to clinch the argument.
Still, the debate offered a revealing glimpse of an area of orthopedics that affects most athletes sooner or later. If it’s not a rotator-cuff injury in a swimmer, it’s an Achilles tendon injury in a basketball player, or, depending on the sport, a tennis elbow or – as happened to me – a hamstring injury.
As I tried to figure out why I might have gotten this injury and what might help it heal, I discovered that misinformation abounds. But there is hope. Somehow, I am much better. Not only does my hamstring hurt less, enabling me to run up to six miles with almost no pain every other day, but ultrasounds showed that my tendon was healing.
Of course, the question of why is the great unknown.
I did three things that might have helped me get better. Maybe it was all of them, or maybe it was just what doctors call tincture of time.
Among the surprises, for me, is that although I’d always called tendon pain tendinitis, it usually is not an “itis,” a suffix that refers to inflammation.
Most of the time, there is no inflammation. Instead there is degeneration of the tendon. So why are we using ice and anti-inflammatory drugs like ibuprofen, and why are some doctors giving us cortisone injections?
“Cortisone shots certainly do not have evidence of value in the long term,” said Dr. Allan Mishra, an orthopedist at Menlo Medical Clinic in Menlo Park, Calif., and the doctor who advocated P.R.P. at that medical meeting. “You may also be right about anti-inflammatory medications,” he added.
Another surprise is that it’s not even clear why tendon injuries hurt, and that sometimes, in fact, they don’t. One hypothesis is that pain arises because small, disorganized blood vessels infiltrate the area as part of the tendon’s attempts to heal.
We would like to think we know why we get injured, or even that we know when we are injured. But tendon injuries can sneak up on people who did nothing they know of to bring them on, or who may not even realize they have them. For example, it turns out that about half of all middle-age people have a torn rotator-cuff tendon, and most of them have no idea about it.
In fact, as Dr. Ronald Adler, chief of the ultrasound division in the department of radiology and imaging at the Hospital for Special Surgery in Manhattan, explained to me, patients who have had surgery – the gold standard – to repair torn rotator-cuff tendons sometimes think they are better and report that their pain is gone, but an M.R.I. or ultrasound scan shows that their tendon has not healed.
Another example of an injury that can appear out of nowhere is Achilles tendinopathy (the preferred word instead of tendinitis). Most who get it are men ages 35 to 45 who are recreational runners, said Dr. Hakan Alfredson of Umea University in Sweden, the expert who advocated eccentric contractions.
But, he added, sedentary people get this injury too, for unknown reasons. Achilles tendinopathy, he wrote, is a condition “with an unknown etiology and pathogenesis.”One possibility, said Dr. Joseph Feinberg of the Hospital for Special Surgery, the doctor who treated me, is that tendons degenerate because they did not get adequate blood flow. That might happen, he said, if there is excessive load on the tendon, compressing areas and preventing them from getting blood. It is thought that is a reason for the common injury to the rotator cuff in the shoulder and perhaps other tendon injuries as well, Dr. Feinberg said.
I don’t know why I got injured. It happened in March, halfway through a seven-mile run. Suddenly, my left hamstring hurt so much I could not continue and could barely walk. But a couple of weeks later I could run again, putting up with a sort of chronic pain.
I like to think that injuries will get better if you wait, but my hamstring pain wasn’t improving; sometimes I could hardly walk the rest of a day after a run.
In June, I finally told my coach, Tom Fleming, that I’d been running injured. He was frustrated that I did not tell him about it, but he also hated not knowing why it happened. He has decided it is a biomechanical problem that might have been prevented if I had just worn a pair of orthotic shoe inserts that I got last year when I was recovering from my first serious injury, a metatarsal stress fracture. I hate those orthotics, though. They change my foot strike and, my coach agrees, slow me down by making me brake with each step.
Anyway, I was wearing the orthotics when I got injured. I did not ditch them until April 20, and now that I am running without them I can’t go back.
I told Tom that maybe the orthotics caused the hamstring tear. Or maybe I tore my hamstring because I might have been favoring my other leg. I had just recovered from the stress fracture and was worried about my right foot, where the bone had broken.
Tom suggested that I see Dr. Feinberg about the hamstring pain. Dr. Feinberg sent me on for an ultrasound exam and an experimental treatment: the blood injection advocated by Dr. David A. Connell of the Royal National Orthopaedic Hospital Brockley Hill, London, at that medical meeting.
It is known that platelets in blood release growth factors, and the hope is that those substances can jump-start the healing process. That is also the idea behind using platelet rich plasma and its advocates say that by concentrating blood platelets they can get a better effect than with blood alone.
It’s not clear whether the treatments really work or whether one of the blood treatments is better than the other. In the case of platelet rich plasma, researchers are starting the sort of rigorous studies that might show whether it is effective. One, directed by Dr. Mishra, involves people with tennis elbow. Another, which is expected to start soon, will involve people with Achilles tendinopathy and will be directed by Dr. John Kennedy of the Hospital for Special Surgery, the doctor who treated me for my stress fracture.
When Dr. Feinberg suggested a blood injection, I leapt at the chance, thinking I had nothing to lose. But I didn’t stop there. When I read that tendinopathy is thought to be slow to heal, in part because blood flow to tendons is limited, I decided that I was already doing something that might help.
Running got blood to my hamstring, but on the days I didn’t run I was spending time on elliptical cross trainers. That got blood to my hamstring, too. Then I added eccentric contractions, doing straight leg dead lifts with weights.
On Aug. 4, a month after I got the blood injection from Dr. Adler, I returned for another ultrasound on my hamstring. It looked better, he said – less degenerated, better formed. And it had been hurting less, too. On Aug. 16, I returned for another ultrasound. My tear had shrunk to half the size it was on Aug. 4 – 1 centimeter instead of 2.
My tendon is still abnormal, but it’s getting better. I’m encouraged and thrilled to be running. And when people ask me if the blood injection helped, I have to say: who knows?
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*The New York Times, PERSONAL BEST, “One Injured Hamstring, a String of Treatments” by Gina Kolata, August 20, 2009
