Misadventures in Running Healthcare

Last Saturday I had a sudden, strange Achilles injury.  I've had trouble with tendinitis (or, as I guess it really should be called now, tendinopathy) in my Achilles several times in the past but have been able to keept the pain at bay with a program of eccentric heel-drop exercises.  Of course, it's hard to convince yourself to put in the time on injury prevention when you're not actually injured, so over the past year or so I've stopped doing the exercises.  I had about two days of general soreness before Saturday's run, and then when I was 20 minutes into the run, I felt a sudden pain and could no longer run.  It was hard enough just to walk the two miles or so back to the car.

I was pretty worried, since the sudden pain sounded a lot more like a partial tear (I did the calf squeeze test to check it wasn't a full tear and it wasn't) than "tendinitis."  And as I was recently saying to my friends Rasmus and Tracy, I wanted to know for sure which injury I was dealing with, because with a partial tear it's disputed whether running during the healing process is a good thing or a bad thing:  http://bjsm.bmj.com/content/38/5/597.full vs. http://jap.physiology.org/content/101/6/1720.full.  So if an MRI did show a tear, I would need to do more research, and probably be more careful, before I incorporated running into my rehab plan.

So, I went to the doctor...and I was dismayed at what I found.  Not at what I found in my tendon fortunately--that was good news.  It looks like there's no significant tearing.  The cause of the sudden pain may have been a muscle pull at the point where the Achilles meets the calf, or some combination of tendon microtears and muscle damage in that area.  What I was dismayed about finding was the quality of the advice I got.

I went to a sports medicine clinic.  One of their doctors, Dr. 2, was listed as specializing in Achilles injuries, so that's who I wanted to see.  On my first visit, Dr. 2 was out sick, so I saw Dr. 1.  I wasn't too bothered about who I saw for that first visit since all I needed was for someone to order an MRI.  But Dr. 1 was nevertheless an orthopedic doctor and so in theory should have had a reasonable knowledge of tendon injuries.  However, he didn't know what eccentric exercises were, despite their efficacy in tendinopathy treatment being shown by studies going all the way back to the mid-1980s and confirmed by higher-quality studies in the late 1990s (http://www.ncbi.nlm.nih.gov/pubmed/23669088 is a good general review).  Dr. 1 was also surprised by the idea of ultramarathons and suggested that I might have to choose between being injury-free and continuing to run long distances.  Dr. 1 didn't ask questions about the type of pain I felt when the injury happened or whether I had previously suffered from tendinitis--I eventually volunteered that information.

Dr. 1 did an ultrasound and thought he might see a partial tear, so he ordered an MRI.  A few days later I met with Dr. 2 to review the results.  As I mentioned above, he didn't see any significant tearing, so we started discussing rehab plans.  He asked whether I had been doing any PT/rehab yet and I said that after I found out the results of the MRI, I had started doing the standard eccentric heel-drop exercises.  His primary advice was that these were bad for tendon healing and that I should stop doing them.  Again, the evidence that these work is about as solid as it gets, e.g. http://www.ncbi.nlm.nih.gov/pubmed/11269583?dopt=Abstract, and the only cases where the exercises might not be as effective are when the tendinopathy is located at the insertion point in the heel or when the patient is not an athlete, neither of which are applicable here.  And of course in those cases the efficacy was only reduced; there was no suggestion that the exercises were harmful.

Dr. 2 also prescribed a (brand name...) prescription-strength anti-inflammatory.  This is unlikely to do me any good (http://www.ncbi.nlm.nih.gov/pubmed/?term=stovitz+robert+johnson and http://www.shoulderdoc.co.uk/documents/nsaids_tendinopathy_2006.pdf) and may in fact do some harm (http://www.ncbi.nlm.nih.gov/pubmed/3511134), not to mention the other standard side effects of NSAIDs.  And that is without even getting into the issues of (a) recent research showing that Achilles tendinopathy is not generally an inflammatory condition, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/, and (b) whether suppressing any inflammatory response is beneficial.

I am frustrated.  On one hand, I only went to the clinic for the MRI results, and I've successfully got those.  On the other hand, considering the high financial cost and time out of my day(s) that going to the clinic took, it would have been nice to get some accurate advice while I was there.  I will continue to design my own rehab plan based on real evidence, and I will keep a copy of the MRI images so that I can bring them for a second opinion if I'm having problems.  As it turns out, Hakan Alfredson, Mr. Achilles Tendon Expert himself, has a clinic in London, and I'll be in London at some point in the next couple of months.

When I left the clinic today, my question to myself was, what has to happen for this standard of treatment to improve?  And what can runners/other injured athletes do about it in the meantime?

I have no answer to the first question.  As to the second, beyond the advice that whenever my friend Dave finishes his injury prevention and treatment book, you should absolutely buy it--it focuses on climbing injuries but the general concepts are just as useful to runners as to climbers, and it is the best advice I've ever seen on injuries--I have two thoughts:

Stop assuming every doctor is equally qualified

Most countries have a longstanding cultural tradition of looking up to doctors and assuming that whatever a doctor says about your treatment must be right.  The problem is that when you stop to think about this, it's absolutely bizarre.  In every profession, there are people who are good at their jobs, people who are averagely competent, and people who are not good at their jobs.  To assume that doctors are somehow exempt from this phenomenon defies logic.  I have certainly seen in law that passing a bar exam is no guarantee of a competent lawyer--there's a reason that legal malpractice suits happen.  In a similar vein, passing medical board exams guarantees a level of base knowledge, and continuing education requirements guarantee additional learning in particular chosen topics.  Neither of those things guarantee that a doctor is current on the research in one particular area, that the doctor is good at interpreting and analyzing new developments in treatment, or that the doctor is good at collecting information from a patient and putting that information to use.

From the standpoint of an injured runner, the sooner the mindset of assuming every doctor is excellent at his or her job changes, the sooner treatment quality will progress.  A simple "Could you explain your reasoning for that?  I read a study which concluded the opposite..." could go a long way towards getting rid of treatment recommendations that are no longer supported by evidence but continue to be made simply because they always have been.  Today I was in a rush and didn't take the time to do this at my appointment, which I now regret.

Ask questions you already know the answer to

One problem for me, as an injured runner who's not in the medical field, is that it can be hard to tell if the medical advice I'm getting is good or bad.   I didn't come up with the most obvious solution to this problem until last year, and I still can't believe it took me 28 years of life to figure it out.  The solution is simply to ask questions you already know the answer to, and use the answers to those as a frame of reference for how seriously to take the answers to the questions you didn't know the answers to.  The way I see it, there are two correct answers to any question you can ask:

     -The actual answer, whether that's a black-and-white answer or an acknowledgement that the issue is a grey area and that there are competing possible answers.

     -A variation on the response, "I don't know, but I can find out for you."

These are equally good in my mind; where things go wrong is when you get an answer stated as a black-and-white answer which is factually incorrect, or an answer stated as a black-and-white answer where it is in fact a grey area.

I do understand that some injuries, particularly tendon injuries, are complex, that there are still a lot of unknowns about their causes and treatment, and that there is a healthy dose of voodoo in many of the treatments that are ultimately employed.  For example, I personally suspect that getting regular massage is the thing that cured by ITB problems, but I know the scientific evidence for this being possible is limited.  In other words, I'm willing to give an unproven treatment option a chance in some circumstances.  But what I experienced with my current injury was treatment recommendations that aren't simply unproven but that are in fact contrary to solid scientific research.  That's not good enough.