March 2021

Expert Opinion: Functional Medicine Takes On Chronic Posterior Tibial Tendinitis

By Robert Kornfeld, D.P.M.

As a practicing podiatrist for 40 years, I have seen thousands of patients. About 33 years ago, I became frustrated with the fact that although many of my patients responded to conventional treatment, many did not, and I wanted to know why. To me, this was the missing link in improving my percentage of successful outcomes.

My traditional podiatry training taught me that in the world of connective tissue disorders, absent frank injury, we were dealing with inflammation that likely was borne out of biomechanical dysfunction. So, understanding that inflammation was responsible for the pain, I would employ protocols to suppress the inflammation, i.e., cortisone injections and prescription NSAIDs. A thorough biomechanical evaluation would be performed and the appropriate exercise and stretching routine would be prescribed along with what I believed to be the most appropriate orthotic. Perhaps some physical therapy (PT) modalities would be thrown in as well to enhance perfusion and accelerate cellular turnover time. And, of course, if this approach failed, I could usually find a surgical procedure that might solve the problem.

But it didn’t always work. There was a consistent minority of patients that failed every attempt I made to heal them. Every practice has these patients. We think of them as kooks. We lose patience with them and blame their failure to heal on their psychology. We feel stress when they return to the office and complain that they’re not any better, or worse yet, that since coming to the office they have gotten worse.

Back to the Beginning

About 33 years ago, I began looking into the stages of human healing and all of the physiologic requirements needed for repairing injured tissue. After intensive study, I realized that I had better start analyzing my patient, rather than base my protocol on the diagnosis alone. Without intention, I was catapulted into the world of functional medicine. Key lesson: functional medicine is not the replacement of drugs with herbs, nutritional or homeopathic medicines. That approach will fail most of the time. Functional medicine is actually working with the patient, after a lower extremity diagnosis is made, to understand why that patient has this diagnosis and why they have been failed by therapies that help the majority of patients. To do that, you must understand a broader, holistic view of who you are treating. “Holistic” or “alternative” medicine has now morphed into a more direct approach to healing patients by understanding the mechanisms of pathology BEFORE the symptoms are treated. We call it functional medicine because it is our goal to restore optimal function of the immune system, endocrine system, digestive system, etc. so that any contribution made to a burdened or inefficient immune system can be addressed and corrected. That means a look at systems as well as epigenetic evaluation.

Here I present a case that will not only introduce you to an entirely foreign treatment paradigm, but may also help those practitioners who have struggled with this population of patients who wind up becoming either chronic (unhappy) patients or leave your practice and bad mouth you as a doctor. There’s a quote I was told as an intern – “A happy patient will tell a few people about their positive experience with you. An unhappy patient will tell everyone they know and meet about how bad you are”…and today, that means on social media too.

CASE PRESENTATION

The Medical History:  In early June of 2020, a 79-year-old moderately obese female patient presented to my office with a chief complaint of pain on the inside of her right ankle and lower leg that had persisted for 12 years. She stated that she had “been to more doctors than I could imagine”. The care began with seeing an orthopedic surgeon after the symptoms were present for about a month. He prescribed NSAIDs and sent her for PT. He told her she had an inflammation of the posterior tibial tendon. After 3 months of PT and NSAIDs, she reported that she relapsed when she went off the NSAID. He told her that at her age (67 at the time), things don’t always heal fast and placed her in a CAM walker. She recalled that her pain diminished dramatically in the boot, but when he told her after 6 weeks that she didn’t need it anymore, she stopped wearing it and the pain returned. Unhappy, she went to a podiatrist. He sent her for an MRI which came back with a diagnosis of posterior tibial tendinitis. He started her on a regimen of 3 cortisone injections, each 2 weeks apart. She recalled it helping her. He also prescribed an orthotic which she wore but did not feel comfortable with.

The relief was short term, and she began to suffer again. She went back to the same podiatrist complaining of the unrelenting pain and he sent her to another podiatrist who he said might be able to help her. She visited the new podiatrist who took a very careful look at her biomechanics and prescribed a different orthotic along with stretching exercises. This orthotic was more comfortable to wear but it did not relieve her pain. She states that she went to other podiatrists and orthopedic surgeons over the next few years, had PT many times, wore a boot many times, took more NSAIDs and pain relievers and had other types of orthotics prescribed, but nothing ever held up.

“With the appropriate detective work, we can obtain answers that can help us identify underlying mechanisms that, once corrected, can unburden the immune system and enable us to use therapies that are not suppressive in nature, but can support the body’s ability to heal and repair.”

Approximately 2 years ago, a friend of hers recommended an orthopedic surgeon who had helped her with a knee problem. She went and saw the surgeon who, based on her history, told her that a cortisone shot would help her. She related the past history of cortisone injections that were short lived, but he insisted that if performed under ultra-sound guidance, it would work out much better. She underwent the procedure and noticed remarkable improvement. For the first time in years, she stated that she was pain free. She began a walking exercise program because she had gained quite a lot of weight over the past 10 years. She was up to 3-4 miles/day. After about 3 months, the pain returned, and her leg and foot were quite swollen. The doctor told her she had overdone her exercise and placed her in a walking boot. Two weeks into wearing the boot, her back became intensely painful. She complained to the doctor and was sent for PT for her back.

After 4 weeks, with her back pain continuing and her foot unable to bear weight without the boot on, she got disgusted. This time she went to another podiatrist. He sent her for an MRI and recommended a chiropractor for her back. The MRI came back with a split tear of the PT tendon at the level of the medial malleolus. The podiatrist recommended surgical repair of the tendon and told her this would be the best way to solve her problem. She underwent surgery in July of 2019. Her experience with the surgery was difficult. There was a lot of pain, the incision became infected and would not close. She developed a lot of lower leg edema. She was sent to a wound clinic and after 5 months of treatment, the incision closed. However, there was persistent pain and edema even 6 months post-op.

At that time, she ceased all care and decided that there was no hope. She would wear the boot when the pain became too much to endure, only now she was using a shoe leveler on the left side to avoid a back issue again and took ibuprofen PRN. In early 2020, her daughter-in-law became a patient of mine and had a positive outcome. She had been trying to get her mother-in-law to come to see me, but she refused until June 2020.

In My Office:  At her first visit to my office, after listening to her history, I performed my physical examination. There was lower right leg edema, intense pain at the proximal end of the incision as well as intense pain at the medial navicular. Palpation also elicited pain bilaterally in the Achilles tendons, dorsal aspect of the 3rd and 4th metatarsals, PT tendons (right greater than left) and peroneal muscles. No other signs of inflammation were present. Physical exam also revealed weak but regular pedal pulses, a delayed capillary return and significantly increased temperature gradient bilaterally. Pitting edema was present on her right lower leg and foot. Her neurological signs were all within normal limits bilaterally.

Her medical history revealed hypertension, hypercholesterolemia, “borderline” Type 2 diabetes, hypothyroidism, GERD, and osteoarthritis of her knees and hands. She reported the following meds: chlorthalidone, rosuvastatin, Synthroid, famotidine and over-the-counter ibuprofen. She also admitted to taking Ambien occasionally and Xanax occasionally. She denied taking any supplements.

Review of systems revealed sleep difficulties, anxiety, gas and bloating after eating, midday fatigue, chronic low level back pain, knee pain bilaterally, hand and finger pain, reflux disease, occasional restless leg syndrome and shortness of breath upon exertion.

“A happy patient will tell a few people about their positive experience with you. An unhappy patient will tell everyone they know and meet about how bad you are…and today, that means on social media too.”

Biomechanics were quite interesting. I had the patient stand and there was obvious medial collapse of her right foot consistent with posterior tibial tendon dysfunction (PTTD). When I asked her if her foot always collapsed this way, she said she didn’t believe so but thought it happened about a year ago. She came in with a bag of 8 orthotic devices, none of which had a medial flange or addressed the collapse adequately. She also exhibited an antalgic gait with a pelvic tilt to the left. Off weight bearing there were the following bilateral findings: functional hallux limitus, rearfoot varus, forefoot varus, hammertoes, dorsal eburnation of the 1st metatarsal head, and diminished muscle power of the flexor hallucis longus and peroneal muscles.

Diet, Sleep, Tests: Here is where the functional medicine approach kicks in. It is my job to discover why this patient did not respond to conventional therapies and failed a surgical procedure. First, I ordered an MRI to look at the current state of pathology. I then needed to look at her diet. Here is where an enormous number of contributors to chronic inflammation can be discovered and rectified. Too many people consume foods haphazardly with consistent consumption of refined foods and chemical additives. Since the largest number of antigens are presented to the immune system through the gut (which is why nearly 75% of the immune system resides there), it is important to see what patients are consuming. She was told to keep a 7-day diet journal and then send it to me. We also know that patients who suffer anxiety and digestive problems usually suffer from adrenal and neurotransmitter imbalances. Elevations in cortisol can lead to diminished activity in the thyroid, ultimately disabling efficient metabolic activity. It also directly suppresses immune activity. Likewise, excitatory neurotransmitter dominance can cause peripheral microscopic vasospasm, which, not surprisingly, is how tendons receive blood flow. Impaired sleep may also be a result of this same issue. Deep sleep is essential for the body’s pathways of repair, detoxification, replacement and replenishment. With sleep issues, the immune system struggles to repair and detoxify injured tissues. To examine these possibilities, I ordered an adrenal stress evaluation and neurotransmitter assay. Gas and bloating after eating can be suggestive of diminished digestive enzyme secretions or, more commonly, dysbiosis. This is a critical issue. If the numbers of active healthy bacteria are low and possibly outnumbered by pathogens, the immune system will not be fed properly. It is the fermentation of complex carbohydrates by the friendly gut bacteria that deliver short chain fatty acids to the gut lymphoid cells for food. This can cycle back to a diet that is high in refined carbs and is delivered to pathogens as monosaccharides for immediate consumption. It also has etiology in slow digestion, over-consumption of food and elevations in stress hormones. This was addressed with a CDSA to look for dysbiosis and pathogen identification. Finally, I ordered an oxidative stress blood test to see how well her body was handling toxins and free radicals.

All of these particular tests were important with this particular patient based on her chronic pathology and the symptoms she reported in her review of systems. Without discovering these answers, treatment would be a shot in the dark and likely doomed to fail again. However, with the appropriate detective work, we can obtain answers that can help us identify underlying mechanisms that, once corrected, can unburden the immune system and enable us to use therapies that are not suppressive in nature, but can support the body’s ability to heal and repair.

Treatment Begins: The only “treatment” administered immediately was a casting for a new pair of orthotics with a high medial flange to control some of the PTTD and first ray cut-outs to stop as many of the effects of a compensated functional hallux limitus as we could.

The patient returned when all test results and the orthotics were in. Most surprising to start was the MRI result. It was positive for two split tears – one just proximal to its navicular attachment and another one just proximal to the area that was previously repaired at the ankle level. There was fibrosis and scarring at the surgical site with suspected soft tissue adhesions. This can easily explain the medial collapse and PTTD syndrome. Her adrenal test came back with severely elevated morning cortisol levels (the diurnal rhythm is normally highest in the morning, but this was off the chart) as well as a dip to low levels around 6PM and again an elevation to high levels in the evening. We would expect to see the levels gradually decrease over the course of the day. Her DHEA levels were in the age-appropriate level. Her neurotransmitter assay revealed elevated glutamate and epinephrine levels as well as low serotonin. The elevation in epinephrine is associated with microvascular spasm. Elevated glutamate can cause sleep disturbances, high reactivity to stress, hypertension and restless leg syndrome, among others. Low serotonin also leads to sleep difficulties, anxiety and carb cravings. The CDSA was positive for dysbiosis. Levels of healthy gut bacteria were low, pathogens were not. Her oxidative stress test showed low levels of glutathione (an important and profound antioxidant system in the human body) and high levels of lipid peroxides (cellular breakdown products caused by reactive oxygen species and free radicals). Finally, her diet journal revealed more than 60% of her diet consumption was carbohydrate (all refined, no complex carbs), and 80% of her protein intake was in the form of red meat. Most notably, she consumed only 1-2 glasses of water daily. The rest of her liquid intake was 3 cups of caffeinated coffee daily and 2 glasses of wine at dinner. Patients like this are usually not thirsty because the body is compensated to function on low water intake. Lack of thirst is usually a sign of dehydration.

Needless to say, the first order was to correct these issues. The adrenal issue was treated with calminative herbs and phosphatidyl serine. The neurotransmitter issue was treated with targeted amino acid therapy where precursors to neurotransmitters are used in conjunction with supportive vitamins and nutrients that enhance detoxification and elimination. The oxidative stress was treated with a comprehensive antioxidant formula and liposomal glutathione. She was also placed on potent probiotics to deal with the dysbiosis.

As for her diet, I have had great success with what I call a metabolic reset diet (usually for 6-8 weeks) where we simply follow the natural diurnal needs of the body. Since detoxification, repair, replacement and replenishment require protein and fat and not much carbohydrate, and they occur predominantly while we sleep, dinner is a protein and fat meal. No carbs are allowed since the body at rest does not need energy producing carbs. In the morning, the patient wakes up protein and fat deficient since it was used during sleep. Consuming carbs in the morning also causes the parasites to thrive since the consumption of unneeded sugars slows digestion to slow assimilation ahead of the more needed protein and fat. Therefore, breakfast is also just protein and fat. The only change I recommended was to minimize red meats since they are high in Omega-6 fatty acids and in excess can feed the pathway of chronic inflammation. During lunchtime, we allow the patient to eat carbohydrates with one huge exception. No refined carbohydrates may be eaten. The consumption and fermentation of complex carbs adds fuel to the immune system in the form of short chain fatty acids. Finally, I had her switch to decaf coffee slowly (since caffeine is dehydrating) and add an additional glass of water daily for the first week, an additional 2 glasses the second week, etc. until she was up to at least 8 glasses a day. This is done because a body compensated to low water intake will not use much of it and the patient winds up running to the bathroom too often if the increase in water is too fast. Interestingly, as they begin to consume more water, they find that they are now frequently thirsty as the body asks for more of what it needs. She refused to give up her wine at dinner. The orthotics were fitted, and the break-in process was explained.

Editor’s Note: Learn More About Prolotherapy

Authors of a recent systematic review and meta-analysis concluded that: “Dextrose prolotherapy is more effective in the treatment of chronic pain compared to saline injection or exercise. Its effect was comparable to that of platelet-rich plasma or steroid injection.” Their analysis included 10 studies involving 750 patients who reported significantly reduced pain scores 6 months to 1 year after dextrose prolotherapy for knee osteoarthritis, chronic patellar tendinopathy, Achilles tendinosis, plantar fasciitis, as well as temporomandibular joint, low back pain, and tennis elbow.

Source: Bae G, Kim S, Lee S, Lee WY, Lim Y. Prolotherapy for the patients with chronic musculoskeletal pain: systematic review and meta-analysis. Anesth Pain Med. 2021;16(1):81-95.

Weekly Prolotherapy:  She returned to the office 4 weeks after beginning the protocol and reported some improvement in sleep, anxiety and digestion. She had also lost 9 pounds. She was able to wear the orthotic without discomfort, but the PT pain persisted. She was seen again 8 weeks into the protocol and reported more improvement in sleep, anxiety, digestion, no more mid-day fatigue and her restless leg symptoms were also much less frequent. At this point it seemed obvious that the body was working much more efficiently. It is at this time that my attention turned to the area of chief complaint. I began weekly injections of prolotherapy. Prolotherapy is designed to cause mild cellular irritation and/or disruption with “proliferants” that stimulate the need for cellular repair. It is a way of changing the signal to a more acute problem, so the immune system stops protecting the unhealed tissue with chronic inflammation. Performed under ultra-sound guidance, the solution is injected around the split tears. The end result is the migration of fibroblasts to the area which ultimately begin the repair process of the tendon. This was repeated 6 weeks in a row at both split tears. At that point, the patient was told to come back in one month to see how well the protocol was working.

When she returned, she reported about a 50% overall reduction in pain. I told her she could begin eating carbs any time of day, but no refined carbs were allowed. She was happy because her HbA1C tested at 5.6, down from 6.4 and she had lost 17 pounds overall. She was pleased. I wanted more for her. I gave her 2 options. One was to do another round of prolotherapy, or I could perform an amniotic allograft injection which is derived from a multi-potent tissue matrix containing cytokines, growth factors, fibrinogen, collagen, hyaluronic acid and messenger RNA. This promotes healing of the involved tissues. In my experience, it works best with a CAM walker to minimize any stresses on the injured tissue. She opted for the allograft but told me could not and would not wear the boot consistently because it hurts her back. I reiterated my feelings about it but agreed to the allograft injection since she was a fully informed patient.

Post Allograft Injection:  She returned 4 weeks post-allograft injection. It was wonderful to see that she had a more natural gait and had lost more weight. She was feeling a lot better in her body. As for the PT tendon, she stated that she felt about 80% improvement overall. The pain intensity was 2/10 and was not consistent. She feels it at the end of the day after being on her feet. She did admit, however, that her knees continue to hurt although not as intense as before and her hands were also less painful, but still stiff and somewhat weak. I told her she could stop taking the adrenal/neurotransmitter support at that visit.

She returned to the office mid-January 2021. She still reported occasional PT pain, but it is now infrequent and mild compared to what she started with. She admits that without the orthotics, she does not feel as good but is happy wearing them since they help so much. I discharged her at this visit with an open invitation to return if anything worsened.

In Conclusion

With this approach, I was able to assist a patient with a 12-year history of chronic pain and return her to functional in 7 months. My practice has grown as a chronic pain practice since most of my patients have made good faith efforts at healing through traditional medical approaches yet failed to heal. Most come to functional medicine as a last resort. I find it a very gratifying way to practice even though many of my patients are very challenging because of the years of pain and compensation.

Robert Kornfeld, DPM, a holistic podiatry pioneer, is board certified in Integrative Medicine by the American Association of Integrative Medicine (AAIM), the American Board of Alternative Medicine, and the American Alternative Medical Association. He is a Diplomate of the College of Physicians – AAIM. His practice, the Chronic Foot Pain Center, is in Port Washington, New York.

“Prolotherapy is designed to cause mild cellular irritation and/or disruption with “proliferants” that stimulate the need for cellular repair. ”

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