Off-Season Rehab with Blood Injections

The Boot

As I noted in a recent post, I’ve been building up my running mileage recently.  Now suddenly I voluntarily underwent a procedure on my left foot that has me in an Aircast boot for the next week with a gradual recovery to running.  Best of all, I get to repeat it all in three weeks on my right foot.  Why the heck would I do this?  The answer: I want to race better and with less pain in 2015.

Why I’m Doing It

Throughout 2015, I had a developing case of plantar fasciitis in both feet, but particularly in my right foot.  The defining moment came early in the season when I was visiting my mom in New Jersey and put in far too many miles in a shoe with too little support.  After that, my plantar fascia ached all year.  I found that it hurt particularly after harder, faster runs– but during my race season, that’s where I spend a lot of my training hours.  I dutifully taped my foot with Leukotape before every run and ran every recovery run with orthotics.  I tried every cure known to mankind for my plantar fasciitis.  The solutions that worked before (I’ve had this injury in the past) just weren’t working now.  I knew I would have to take care of this injury during the off-season with something “more aggressive.”  Oddly, my injury was actually improving quite a bit with the increase in running volume that accompanied polarized training– but I had a strong feeling that it was going to come back and bite me the moment that my high-intensity work started again in the spring.  After all, connective tissues (e.g. ligaments and tendons) tend not to heal on their own once we pass out of our teenage years.

That “more aggressive something” was an autologous blood injection under ultrasound guidance into my plantar fascia.  I’ve had great luck with these kinds of procedures in the past.  As I noted, ligaments and tendons tend not to heal on their own.  Also, if you’ve had a new case of “tendinitis” that didn’t heal in a week, chances are that it’s not tendinitis but is instead a much more awful condition called “tendinosis”– a swelling accompanied by poorly-formed collagen that tears under the slightest tension.  The reason our bodies do such a lousy job at healing tendons and ligaments has to do with diminished blood flow to these tissues– and all the ultrasound, hot compresses, and EMS in the world by your PT isn’t going to get enough blood flow going in these areas to make a difference.

What Are the Options

Instead, the answer is to use your body’s own healing mechanisms to stimulate the influx of blood and other healing factors.  Here’s a quick summary of the different options from gentlest to most invasive (and expensive).

  1. Prolotherapy.  This procedure involves injections of an irritant (other a sugar-based solution) directly into the tendon or connective tissue.  The irritant doesn’t bug the patient consciously (except for the needles) but it doesn’t irritate the body’s repair system and causes the body to kick start its repair processes.  The doctors using this procedure will stick you with a needle about 3-6 times in each– but experienced doctors are magical in making it not-so-unbearable.  It can (but usually isn’t) done under ultrasound guidance (some of my most successful cases of using prolotherapy were not under ultrasound guidance).  I used prolotherapy successfully to avoid surgery for a case of rotator cuff in my shoulder and achilles tendinitis in my right foot.
    • PROS:
      • Not as invasive as other methods– you can be running after two days.
      • Very effective with early injuries– much less effective with older injuries.
      • With “younger” injuries, you’ll either be fine in a month or two or will need more aggressive procedures in the off-season.
    • CONS:
      • Not as effective as other methods for older injuries.
      • Likely not covered by insurance.
      • Requires multiple visits (usually about 3-4 visits one week apart).
      • Reasonably expensive– expect to shell out $500 to $800 over the course of treatment.
  2. Autologous Blood.  This procedure replaces the irritant solution of prolotherapy with a few milliliters of your own blood.  The idea is to get some of the healing factors of your own blood together with a little clotting.  By using blood, it gets your body jump started in using healing signals it is used to.  Suddenly, blood starts flowing into the tendon/ligament for the first time since you were a teenager and healing magically happens.  This is the procedure I just had done on my left plantar fascia.  It should also be done under ultrasound guidance.
    • PROS:
      • Much more effective than prolotherapy.
      • Works with older or chronic injuries.
      • Usually (but not always) paid for by insurance.
      • Doesn’t require multiple visits
    • CONS:
      • Slightly (but significantly) less effective than PRP.
      • Invasive– you’re in a boot for 1-2 weeks and then it’s a gradual rehabilitation back.
  3. PRP Centrifuge TubePRP (Platelet Rich Plasma).  This procedure is virtually identical to autologous blood, except a larger sample of blood is initially drawn and it is then spun down in a special $250 centrifuge tube (shown at right).  The idea behind the expensive tube is that it has spacers of very specific densities– once the tube is spun, the red blood cells settle near the bottom, the liquid plasma floats to the top, and right between the two is a thin layer of platelets and other healing factors.  That thin band includes all the “good stuff” that your body uses to repair itself.  In fact, there’s even a small amount of stem cells supposedly floating around in there!  The tube at the right is my blood in a PRP tube when I had my left achilles tendon injected.  I had this procedure done on a five-year old case of achilles tendonitis that was slowly destroying my running.  Under ultrasound, my achilles was trashed, with a long longitudinal tear.  One PRP injection and I was fine within a year (I may repeat it down the road but it was a miracle cure given how badly it was affecting my running up to that point).
    • PROS:
      • Most effective procedure for tendons and connective tissue
      • Doesn’t require multiple visits.
    • CONS:
      • Not covered by insurance– usually about $900
      • Invasive– just like autologous blood.

Choosing a Doctor

Each of these procedures have mixed results in the literature.  I attribute this to the practitioners who are actually doing the procedure.  I once chatted with a podiatrist who complained about his lack of success with PRP and recommended a special $10,000+ stem cell procedure instead.  Always beware of a doctor who dismisses a field that others succeed in.

In short, you want the most professional and experienced doctor possible doing this kind of procedure.  I live in Seattle and the University of Washington is amazing with PRP– probably because the University has a great sports program (including a great running program) so the doctors have lots of opportunities to hone their craft.  Dr. Kimberly Harmon at UW is particularly well-known in the sports medicine field for PRP.  If you don’t live near Seattle, I’d recommend finding some sports-crazy university near you and contacting their sports medicine clinic– chances are that you’ll find an excellent doctor who has performed thousands of PRP injections.

Finding a good prolotherapy doctors can be a little more challenging.  More often than not, their offices advertise “pain relief” for a myriad of different injuries.  You usually don’t find them in traditional medical practices because the traditional medical field treats prolotherapy as a “fringe” area.  When I was in DC, I had amazing success with Dr. Mayo Friedlis and it seems that he has quite a reputation in the field.  If I were looking for a good prolotherapy doctor, I’d call his office and ask for a local recommendation.

Why You Want to Do it Now

Given the invasiveness of the procedure, PRP and autologous blood treatments are best reserved, whenever possible, for the off-season.  I had planned this visit to the doctor all year long.  My feeling is that there is no sense making a minor injury into a season-destroying injury down the road by ignoring it.  I also didn’t want to do prolotherapy because, while my symptoms were new, the injury itself was anything but new.  Also, I have the most sensitive feet in the world– if someone is going to stick a needle in it, I only want it done once (for plantar fascia, they usually first inject a nerve block near the ankle which numbs the entire foot)

Older athletes– and particularly older endurance athletes– can be stubborn, thickheaded people.  We honor those who suffer through pain and make it to the finish line.  We watch videos of Gabriele Anderson-Schiess (staggering to the finish line in the 1984 Olympic women’s marathon) or John Stephen Akhwari (limping with a broken leg to finish last place in the 1968 Olympic men’s marathon) for inspiration and courage.

But there’s a difference between courage in a defining, once-in-lifetime event (like an Olympic marathon) and stupidity in not addressing everyday problems that are holding us back.  The off-season is the time of year to take care of these problems so they don’t come back to haunt you during the rest of the year.  There’s nothing brave about stubbornly ignoring a hotspot in your body during your off-season.  Instead, it’s just plain dumb to not take care of these performance-limiters now.  Save the heroics for that trip to Kona.

Is it Legal?

Being a lawyer, I’m sensitive to hyper-technical arguments.  By taking blood out of our bodies and then reinjecting it, isn’t this technically blood doping?  After all, Lasse Viren is often held up as an example of blood doping.  The idea is simple enough– you take out your own blood and store it in the refrigerator weeks or months ahead of a big event.  In the meantime, your body makes new red blood cells to make up for the deficit.  Then you transfuse the blood back into your body– thus giving you a huge surplus of hemoglobin and a big advantage over your competition.  By removing and reinserting the same blood, isn’t autologous blood injections and PRP really blood doping?  Even worse, because PRP concentrates specific growth factors in that thin layer, isn’t a PRP injection also close to having a testosterone injection? (BTW, if you’re an older guy being treated for low-T, chances are almost certain that you’re violating WADA’s rules and can be banned from competition if you get tested).

Of course not.  First, so little blood is actually reinserted into your body that you actually end up slightly on the negative side of the equation, hemoglobin-wise.  Second, the time delay between the removal and reinserting of your blood is about 15 minutes, whereas it takes many days or weeks to make up the difference in hemoglobin from a blood transfusion.  While WADA (World Anti-Doping Agency) once actually prohibited PRP, that position is changing.  PRP is now specifically permitted under WADA guidelines.

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