Weak tendons -- what to do?
April 8, 2014 6:55 AM   Subscribe

My boyfriend has been having orthopedic injuries that are intense and debilitating for a day or two, and then disappear. He saw a doctor this morning that said it's possibly caused by weak tendons or ligaments, but didn't offer suggestions on the underlying cause or preventative measures. YANMD, but what sort of doctor should we look for?

My boyfriend is in his early 30s, average weight and height, and does not exercise very often other than the occasional game of tennis.

Last week, he twisted his ankle while walking, felt searing pain, and was immobile for two days. He did the usual rest, ice, compression, elevation routine, and it seems totally fine now.

A few months ago, he woke up one morning with a swelling in the other ankle (although there was no specific injury), with the same symptoms: intense pain and inability to walk. This also settled down in a couple of days.

The biggest issue is that for the last six years or so, he's been having sharp pains in the lower back off and on when he runs, sits still for too long (as when driving), or even when he eats too much.

We just went to an orthopedic doctor at the health care center of the university where he works and described these three problems. The x-ray of the recently injured ankle shows nothing conclusive. We got an x-ray of the back as well but don't know the results yet. The doctor posited that there is a general tendency of weakness in the tendons and ligaments, but said that he should continue usual activity (including running or hiking), and come see him if there's another injury (duh!). He did not offer ideas on how to prevent further injuries or strengthen the tendons.

I'm dissatisfied with this, since we don't have any sort of solution or explanation other than general "weakness." What sort of specialist should we see that will be more helpful? An orthopedic unit at a hospital, a physical therapist, a sports medicine doctor, etc.? Specific recommendations in the Boston area would also be great.

If you've had a similar problem, what do you do to keep it under control?
posted by redlines to Health & Fitness (15 answers total) 3 users marked this as a favorite
I don't mean to throw shade at anyone, but student/university health centers are notorious for being staffed with doctors who can be, shall we say, less than proactive. I'm disappointed but not particularly surprised about the care your boyfriend received.

Since it sounds like he doesn't have a primary care doc, I think your best probably is going straight to an orthopedic surgeon at one of Boston's very fine academic medical centers. There may be a few weeks wait for this, during which time I would refrain from running and hiking, were I him.

I am not a doctor and I won't hazard an internet diagnosis, but I can think of many things that this could be that are real and treatable and "wait and see if you keep spraining your ankle all the time" strikes me as bad advice.
posted by telegraph at 7:09 AM on April 8, 2014 [1 favorite]

I'm not a doctor, I'm just a guy on the internet with a crappy body.

Does this characterization of ligamentous laxity sound like it might describe the underlying problem? It seems a little less wooly that "weak ligmaments" to me, at least.

Regardless, if I had problems along these lines - and I do - I would see an(other) orthopedist/sports medicine specialist (for the tendon/ligament angle) or, alternatively, a rheumatologist (for the chronic joint and inflammatory problems). If the problem is in fact an underlying chronic ligament issue that's aggravated by particular activities (e.g. running) rather than a series of essentially isolated acute injuries, a rheumatologist might have more helpful treatment insights.
posted by onshi at 7:29 AM on April 8, 2014

Seconding seeing a non-student clinic doctor, even just a GP. An X-ray cannot tell you anything about tendons. Orthopedic Surgeons are surgeons. Lots have the attitude of "the bone/cartilage/tendons are fine, so it's not my problem". They don't really have any tools in their toolbox outside of surgical care.

There are, of course, lots of levels between surgical care, and doing nothing. A better doctor will be able to suggest some. I wouldn't want to guess if there is some overall problem with your boyfriend like arthritis, but that should be ruled out too.

Either way you go about it, I recommend asking about physical therapy. Depending on how your insurance works, you might need a referral to see a physical therapist, and then you might have a limit on how many sessions you can have. But I would recommend seeing a PT, explaining your problems, and trying the exercise routine they offer in earnest.

Generally speaking, tendons/ligaments hold your skeleton/limbs/joints in place, but to a larger extent, so do muscles. If the diagnosis of "weak tendons" holds true, I would guess that this guy has either low muscle tone, bad form/posture/ergonomics, or hyperextensive/hypermobile joints which are more prone to stressing tendons. A PT eval will reveal either or all of these.

The treatment of these different causes will take two general forms: gain more muscle mass to take stress off tendons, or get support and correction through brace/tape/supportive shoes/etc and take stress off tendons. Through this, pain will be lessoned, and re-injury will be reduced.

I know some will recommend seeing a podiatrist and/or chiropractor. I think these specialties are far too prone to quackery and woo. (Or, perhaps PT is just my favored form of placebo and chiro is someone else's.)
posted by fontophilic at 7:33 AM on April 8, 2014 [1 favorite]

Regarding treatment (irrespective of specific diagnosis), fontophilic said what I should have.

The basic idea is to strengthen muscles through specific exercises while building habits (muscle memory!) to rely more on those muscles them to support the body as opposed to the affected ligaments.
posted by onshi at 7:41 AM on April 8, 2014 [2 favorites]

You need to talk to a primary care doctor. Not all joint pain is orthopedic. There are a number of other causes and contributing factors to rule out.
posted by the young rope-rider at 7:44 AM on April 8, 2014

Brush your teeth while standing on one foot. Swap feet.

My sister runs marathons and this is her ankle strengthening trick.

Also look into orthotics. They removed my soccer-related knee-pain completely. Its amazing how much a wee little mis-alignment can throw the system out of whack.
posted by St. Peepsburg at 8:07 AM on April 8, 2014

Hi! I was in your boyfriend's shoes about 2 years ago. I kept on spraining ankles, got weird joint pains (usually in my feet), and also nearly ruptured a tendon completely. I understand how frustrating this is because it also took me quite a long time to figure out what was wrong!

While the orthopedic podiatrist I saw for when I seriously messed up a tendon in my foot was able to accurately diagnose me for that (after X-rays AND an ultrasound), the person who helped me the most was actually my physical therapist. She had a background in dance so was really into helping rehab lower body injuries. In one of my first sessions, I mentioned rolling my ankles a lot and she tested me to see if I was hypermobile. Turns out I am.

The fix? Lift heavy weights. Having more muscle mass will help stabilize joints since there will be more support to help hold everything together. My PT started me on working through just body weight exercises first, but then I started lifting heavier and heavier weights on my own. I haven't had any of my previous joint pains since!

The doctor I saw also recommended that I get orthotics (custom made ones...) though my PT wanted me to strengthen myself first. While I did end up buying a pair of expensive SuperFeet insoles, I ended up not using anything and chose to work on weights instead, mainly because I didn't like the idea of being dependent on orthotics to make the pain go away.
posted by astapasta24 at 8:14 AM on April 8, 2014 [3 favorites]

"Brush your teeth while standing on one foot. Swap feet."

Just a data point: I have problems along the same lines, and doing this actually hurt me. I know it's pathetic, but there you go. It may take more careful strengthening and introduction of new exercises depending on the severity of the problem.
posted by onshi at 8:15 AM on April 8, 2014

I came to say what astapasta24 said. This all sounds very familiar, except for me it is unstable shoulders and hips, loose SI joints, frequent low back pain, hips are screwed, elbow and wrist pain, etc. and I've just turned 30. It's eponysterical maybe, but assuming this is "just" ligament laxity, he needs to bring his musculature up to make up the difference.
posted by mrbigmuscles at 12:43 PM on April 8, 2014

I would be careful with any advice that says to lift heavy weights. That can cause all kinds of problems, and in fact messed up my tendons.
posted by Dansaman at 1:08 PM on April 8, 2014

I had tendon and ligament injuries in my dominant hand and arm and all the way into my back. It was due to a sports injury in college. It was very impairing, sometimes making it challenging to even get out of bed. I took gelatin daily as a supplement for a year or two to feed the tendons and ligaments and strengthen them. My problems have never been as bad since.
posted by Michele in California at 1:23 PM on April 8, 2014

Rheumatologist, to exclude inflammatory conditions and oddball systemic diagnoses.

A lot of people with multiple and chronic ligamentous injuries never find out what caused it. Even good imaging (no technical error; valid interpretation by a radiologist) might not capture a thing, if it's not where the referring doctor thought it was. There are umpteen causes of weirdo pains. Fluoroquinolone antibiotics, like Cipro, have been linked to tendon rupture. Long-term use of NSAIDs can compromise tendon healing. Congenital laxity might incline a person to injury due to insufficient strength of surrounding stabilizers. Connective tissue disorders* can mess with a lot of things, and can vary in the degree of their severity and effects - people sometimes find out about these in their 20s and 30s in crops of injuries. One untreated injury can have a cascade effect on general biomechanics, and post-injury compensation can screw things up too; chronic injuries can screw with your nocioceptors over time and make it so you interpret pain where there might be other signals. Finally, in tendinosis, which is not inflammation, but failed collagen healing (scarring), the cellular and biochemical actions prompting the scarring are not really that well understood. There is good evidence for use of particular PT exercises for some injuries, but not all.

Much of the time, what people with weird and chronic ligament problems are limited to is symptomatic treatment of each injury as it happens, with the goal of getting back to a given level of function**. IMO, the people best suited to help with that are physical / physiotherapists and podiatrists, who can help with orthotics to address biomechanical issues. (Some PTs are really opposed to orthotics; others are happy to include them. Different treatment philosophies.) I would not, myself, go to a chiropractor - their training, in North America at least, is pretty controversial and unconvincing to me, but do look into it for yourself.) Surgeons can only help with straight-up, easily imaged problems. Lots of times, people aren't so happy with outcomes of surgery, in any case (though many people are).

I would go to a PT based at a sports med clinic, in case a referral needs to be made (to a rheum or someone else). And would look for a PT who keeps up to date in a range of treatment modalities (like not just BLABLA (TM) ). They should know the difference between tendonitis, which is really rare, and tendinosis, which most people deal with when they have a tendon thing. They should be able to talk about evidence-based treatments for particular injuries. Be critical, but keep an open mind to what's presented. I had to be persuaded to try it, but electro-acupuncture helped with chronic injury in a tendon that couldn't be remodelled through PT exercises (because its anatomical location meant it was impossible to create enough force that way to initiate healing, which amounts to better organization and form of collagen fibres, for tendinosis anyway - the explanation of this rationale made sense to me, which is why I tried it. Lucky me - it helped.)

*The problem with these is, most GPs are not really up to speed on things like Ehlers-Danlos syndrome. When they are aware of them, they are sometimes looking to see textbook and extreme examples of hypermobility and skin symptoms, and may not catch milder manifestations. Some variants of connective tissue disorders can be fatal; the great majority are just treated as and when, symptomatically, with injury-specific PT and ortho treatment. A geneticist can exclude some of the scary things. The benefit of doing that would be in terms of family planning, and to forewarn any surgeons in terms of special techniques in case surgery is needed.) Mild hypermobility can combine with the normal wear and tear of osteoarthritis over time and just lead to a mess.

**That standard and those goals are different for young athletes than they are for diabetics in late middle age. So a sports injury clinic, where folks support athletic goals, may be better for your husband than a clinic where most patients just want to be able to go grocery shopping.
posted by cotton dress sock at 1:26 PM on April 8, 2014 [3 favorites]

Does he take fish oil? No, NOT the capsules. I'm referring to 1-2 whopping tablespoons of the big guns, liquid fish oil. I promise it is not as vile as it sounds - this particular type tastes like lemonade and you can get it at whole foods.

I run 5-9 marathons a year and gawd-knows how many other races and mileage and I swear this stuff not only keeps my joints healthy, but my tendons and ligaments in working order.

Definitely echo getting checked by a rheumatologist just to rule out the scary stuff.
posted by floweredfish at 2:06 PM on April 8, 2014

*sorry to be clear, I was rushing earlier: the electro-acupuncture was done alongside manual therapy (massage) - that is what accomplishes the breaking up of the nasty tissue.
posted by cotton dress sock at 5:10 PM on April 8, 2014

As someone with a lot of joint/tendon problems (elbows, knees, achilles) I'd strongly endorse going to see a physiotherapist or sports medicine doctor and possibly also a podiatrist. They will be able to do tests and get detailed information that will enable them to diagnose the specifics of your boyfriend's problems more effectively than a bunch of strangers on the internet. I would really advise that your boyfriend not start doing a bunch of exercises or lifting/holding weights etc on the theory that it helped someone else who might have a completely different set of problems.

Physio has helped me with tennis elbow, acute lower back pain, osteoarthritis and general weakness of the knees, plantar fasciitis and achilles tendinopathy (my current worst ailment). Podiatry has helped with most of those as well. They're both solidly evidence-based forms of treatment with little woo and a lot of common sense and are a good place to begin. My problems have been treated with a combination of stretches, strengthening exercises, orthotics, finding different kinds of activity that assist with strengthening/stretching.

I've tried (off my own bat, not at the recommendation of any of these professionals) supplements like glucosamine, magnesium, flaxseed oil, devil's claw and I can't say I feel they've made a huge amount of difference. If you are interested in that aspect it's good to know a bit more about the validity of claims; this is a useful infographic which tracks the scientific evidence for health supplements for specific ailments. Fish oil, for example, has stronger evidence for assisting with cancer symptoms and depression than it does for child intelligence or cardiovascular disease.
posted by Athanassiel at 11:35 PM on April 8, 2014

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