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Tender tendons take time to heal

It was back on July 16 that David Ortiz tweaked his right Achilles' tendon trying to downshift from a run to a trot after Adrian Gonzalez hit a homer to left. While it was not the most dramatic injury that Papi has suffered, it's likely among the most nagging. It's been five weeks and counting since he limped off the field at Fenway and out of the line-up. Considering that it was one small misstep, it turned out to be a pretty significant setback.

"I actually see a lot of injuries like that in my practice," said Dr. Naven Duggal, head of Orthopaedic Foot and Ankle Service at Beth Israel Deaconess Medical Center in Boston. "Sometimes it takes very little to cause an injury and when you're dealing with the Achilles there is no quick fix."

Ortiz had an MRI that ruled out a tear or rupture. The Sox DH himself has referred to the problem as tendinitis. He wore a boot for while but didn't feel much improvement. In early August he tried an injection to numb the area and experienced some relief -- until the medication wore off. It seems rest is the best medicine.

"It's not the answer many of my patients are looking for. When I tell a marathoner that they are not going to be able to run for a while they're not happy. I imagine that David Ortiz isn't having the best time of his life but frankly, both non-surgical and surgical solutions can take time to be effective."

Tendinitis is an inflammation of the tissue sheath that surrounds the tendon. It can be caused by overuse, a sudden increase in workload (like changing your daily workout from a walk to the fridge to a one mile run) or a quick strain from misplacing your foot on the base paths.

Even if Ortiz (or for that matter you or I) had been diagnosed with a partial tear that would not necessarily have meant surgery. Where the tear is located impacts the approach to treatment. While acknowledging that each case is different, Dr. Duggal indicated that if the tendinitis is located in the mid-tendon he would be much more likely to take a conservative approach and advise rest, partial immobilization, physical therapy including eccentric strengthening and perhaps a heel rise or orthotic.

"The tendonitis and partial tears can occur in the mid substance of the tendon or the insertion point - where the tendon attaches to the heel. But surgery is not indicated for all patients. The decision depends upon a number of factors, including length of non-operative treatment, severity of disability, and even what they do for a living."

The Achilles' is the strongest tendon in the body but it has its limitations. Tendons have a more limited blood supply than muscles and other organs, so repair and recovery take longer. Athletes, being notoriously impatient patients, often look for therapies that offer hope of accelerating recovery from injury. Injections of platelet-rich plasma or PRP have received a lot of attention lately especially after the likes of Kobe Bryant, Tiger Woods and A-Rod reported using PRP to treat soft tissue injuries.

"PRP therapy involves taking some of the patients own blood and putting it into a centrifuge to separate it into its various components. The platelets are then removed and injected, in a concentrated dose, to the injured area. The idea behind it is that the high concentration of platelets along with growth factors, which do play a role in the repair and regeneration of tissues in the body, will enhance that process. Right now the data I have seen for the Achilles' is a little bit murky."

Time may not actually heal all wounds (or injuries) but Ortiz reportedly feels he's close to a return after being out for a considerable stretch. And speaking of stretching ...

"Sometimes there is nothing you can do to avoid an injury, but there are ways to increase your chances of staying healthy. We lose flexibility as we get older so stretching is important," explained Dr. Duggal. "Changes in shoewear, training schedule or even running surface can trigger an Achilles' tendon problem. If you are planning on starting a new exercise regimen be smart about it and increase your activity gradually. When you hurt don't try to push through the pain."

And if you're David Ortiz, you might want to avoid sudden acceleration or deceleration when possible. Home run trots are preferable.