Interview with Benn Boshell

Hey everybody! 

Welcome to our fourth episode of the Ankle Surgery Update. We would like to thank you all for supporting us and the feedback we have received. Our main intention is to present and discuss recent literature. But through your valuable feedback, it became apparent to us, that literature, throughout the world, is interpreted and lived differently. Therefore, we decided to introduce a new section to our podcast: Interviews with authors and experts in the field.

Therefore, it is our great pleasure to introduce our first interview guest to you: Benn Boshell! Ben is a podiatrist from the UK and Head of Service at Hatt Health & Movement Clinic. He is the author of “The Plantar Fasciitis Bible” and hosts the podcast “The Heel Pain Expert Podcast”.

The three of us had a great chat on insertional tendinopathy of the Achilles tendon. We focused predominantly on the appropriate diagnostics and non-surgical treatment approaches.

Thank you very much for listening to Ankle Surgery Update – Science Guiding Treatment. We hope, you will enjoy this new format and we are happy for any feedback! And of course, we hope you tune in next month again!

Hans & Sebastian

Transcript

Unknown Speaker : 0:10

Hey everybody, welcome to our fourth episode of Ankle Surgery Update. For us in Germany COVID restrictions are being eased and the patient load is increasing again. It will be exciting to see which of the tools such as video outpatient clinics and meetings will stay in place. But for today, we're extremely excited that we will have our first interview podcast. In the future. We'll try to find a balance between interviews with experts in the field and discussion of novel editor

Unknown Speaker : 0:39

today. We are very happy to have a guest it's Benn Boshell from the UK. He is podiatrist and is hosting his own podcast. We're very happy to have you Benn. Maybe you introduce yourself quickly.

Unknown Speaker : 0:51

Yeah, sure. Thank you for that. So yeah, my name is Benn Boshell I'm a podiatrist based in the UK and I am the head of service at Health and Clinic which is in the southwest of the UK. I'm also author of the Plantar Fasciitis Bible. And I host a podcast called the Heel Pain Expert Podcast.

Unknown Speaker : 1:12

Also from my site, great to have you here on our podcast. I think for the two of us, it's actually the first interview style podcast that we do. So that is exciting. And we chose the topic of insertional tendinopathy of the Achilles tendon. So do you have any specific diagnostic approach? If you see patients in your outpatient clinic?

Unknown Speaker : 1:32

Yeah, I think insertional tendinopathy is quite can be quite tricky from a from a specific diagnostic point of view. It's in my experience less common than mid portion tendinopathy. And when I do encounter insertional, Achilles tendinopathy is there are sometimes some other features going on, such as an apparent bump, which may be a bony exocytosis or may may just be the Scientists so I do find a clinical examination loan is can be quite tricky to make sure you're actually on the right tracks and and I do value diagnostic imaging to try and get a bit more accuracy on diagnosis, so what tools do you use for imaging.

Unknown Speaker : 2:14

So at the moment, I don't have immediate access to ultrasound in the clinic, which would be a godsend, because that would really help with making a clinical diagnosis there and then with my patient in the room, so I do sometimes diagnostic ultrasound, or I go for MRI, I don't tend to refer for x rays. For this condition. I think an X ray may show that there is a bony exocytosis but that's not necessarily going to tell me why the patient is symptomatic it it's going to give me limited value on what's going on in the Achilles tendon in terms of the tendon fibres. And it's, it's not really going to show me much with regards to bursitis either, so I would tend to lean towards either MRI or ultrasound.

Unknown Speaker : 2:59

So you're already making And that if you look at the attendance at the quality of the tendon on the MRI at the hospital bursitis What else do you do you look at what else and what what impact does it have on your treatment approach?

Unknown Speaker : 3:10

Yeah, so I, when I refer a patient for an MRI, it's done at a local hospital. And there's a good team of musculoskeletal specialists, radiologists, and they are far more expert than I am at interpreting MRI results. So I do rely on my colleagues to tell me what they think they can see going on. And then once they've written their report, I'll then focus on what those findings mean and interpret that to the patient. I think the most frequent things I tend to see with when dealing with insertional pathologies is insertional tendinopathy, you know of the tendon itself. And commonly there is signs of retro cranial bursitis. So those are probably the two key things I'm looking for. I am interested if there is a superficial cranial bursitis she's obviously quite different. condition and you'll have different causative factors related to it. And I'm interested in the mid portion of the tendon is actually healthy as well.

Unknown Speaker : 4:07

So what different treatment approaches do you take? For example, if you see a bursitis versus tendinopathy? Do you make any difference regarding the treatment?

Unknown Speaker : 4:15

It's good question. I find that if somebody has retro cranial bursitis and it shows up positively with an ultrasound or an MRI, I do find them more tricky to treat conservatively. And what I think does work well is an ultrasound guided corticosteroid injection specific into the retro cranial Bursa, I find that a very irritable and don't settle down very easily if the MRI or an ultrasound didn't identify bursitis but just insertional tendinopathy then I will be leaning more towards shockwave therapy as a treatment option. And shockwave therapy has been demonstrated to be effective for tendinopathy but not for the situs. If anything, it probably just makes the bursitis more angry. In my opinion, because you're hammering away on a sack of fluid, which is already compressed and irritated. So I don't see how shockwave therapy is going to help with that. So I think the intricacies of what's going on pathologically do influence the non surgical treatment plan.

Unknown Speaker : 5:13

That's really interesting. You talk about regular tendinopathy. Do you also look at the muscles? Whether they have a Gastroc tightness there or not? Does that play any role?

Unknown Speaker : 5:22

I'm not certain how relevant it is. And I think that's based on what I've read, and what I've learned, listening to other colleagues, you know, internationally, who have PhDs on, you know, on the subject of Achilles tendinopathy. And it doesn't seem to be a consensus from my understanding that gastroc or Achilles tension is related to intended properties. And a lot of a lot of experts I know suggest not to stretch because that doesn't seem to be beneficial. So I'm not sure how important it is. I think, incidentally, I see lots of it. So I think most of my patients who have insertional tendinopathy often do have gastro anaemia. So And I'll do the common clinical silverish called test to assess for that, but what I'm not certain on is whether that is incidental as opposed to causative.

Unknown Speaker : 6:09

So that's very interesting. Again, you don't prescribe stretching therapy

Unknown Speaker : 6:13

With Achilles tendinopathy. I prefer to lean towards loading exercises. So doing more strengthening the loading exercises for the tendon and having an emphasis on eccentric loading that seems to have although limited quality evidence, it does have the best evidence which exists at the moment. With regards to stretching, I do give my patients stretching exercises to do because although I'm not convinced that there is a causative link, I'm not also confident that it's not relevant. So as long as it doesn't aggravate the patient's symptoms, I'm happy for them to be stretching, but I do sometimes find that with insertional Achilles tendinopathy, particularly doing stretching exercises irritates it, and that could be perhaps because that tendon is going to apply a bit more compressive stress to the retinal cranial Bursa when such staining a maintains dorsiflex position. But that's just what's going on in my head. I can't prove that

Unknown Speaker : 7:04

That really is interesting. I think in Germany, we do interpret the literature a little different for us, more pronounced and mid portion, but also for insertional, tender pythia. We do have the feeling that if they do have a gatroc tightness, and they do stretching exercise, round about 70% will experiences a severe decrease in the symptoms over time, it's not going to resolve it in a week or two. But we usually tell our patients to do it for eight weeks straight and actually do it twice a day for 10 minutes. And there I think there's a protocol from from the Dutch published that recommends that and they even recommend 30 minutes if I'm not mistaken. And we actually do have pretty good experience with that right? And

Unknown Speaker : 7:46

Actually, we do the eccentric stretching, not only if we observe gastrocnemius tightness, but even if we don't observe that and they just have an insert in search, no pain. So actually, we prescribed this in every condition of insertional pain, even in bursitis. We do that, and this is our first line treatment. And if that doesn't work, then we will progress.

Unknown Speaker : 8:12

It definitely does. But I think Ben is totally right. The vast majority, or at least a big majority of the patients within search, nothing new, but the gonna have positive. So let's go test.

Unknown Speaker : 8:22

That's right. That's right. That's a good coincidence.

Unknown Speaker : 8:26

It is. And I think this coincidence has not been studied enough yet. I am not aware of a lot of studies really demonstrating this link. But I'm convinced there is a link but it has not been focused on I believe

Unknown Speaker : 8:38

That's very interesting. So I feel that way about plantar fasciitis. So when I'm treating that I am very, very, very pro stretching. So that is the most important aspect of my treatment. And I think there is good evidence to prove a causative link between gastroc Aquinas and plantar fasciitis and I think Here in the UK, a lot of the physiotherapy and podiatry profession were very pro stretching exercises for insertional Achilles tendinopathy. Also, it's still popular for plantar fasciitis and the research is there to support that. But I think for insertional tendinopathy in the UK, at least, it seems to have fallen out of favour. And I suppose I've been influenced by, you know, what other experts are saying and other people's opinions. And so I'm not as convinced there is a cause there. But I also agree that I don't think it's been studied robustly enough to actually know to come

Unknown Speaker : 9:33

You said if they have bursitis, you're going to do a glucocorticoids injection. Do you just do that once or if the patient does experience severe decrease in pain, or let's say, for a year, would you repeat that?

Unknown Speaker : 9:41

That's good question. I rarely see people that don't respond well to it. If they don't respond well to it. I personally prefer to refer them on to a paediatric surgeon or an orthopaedic surgeon. To get their input on whether they think it's time for surgery or whether they would be more willing to try a second corticosteroid injection. So my approach is I'll refer a patient to receive one. I used to do it, but I don't have an ultrasound machine in the clinic anymore. So I can't currently do that myself. But I do refer them on to a radiologist that can do it. And I do find it works really, really well. When the pain recurs. That's when I'm referring on for a second opinion, really, just to make sure I'm not missing anything. And I think it's just always good to get somebody else's opinion. If somebody is not responding to a treatment plan

Unknown Speaker : 10:30

That actually is really interesting how you proceed because for us, we do also do the glucocorticoid injection, actually, we do it independe whether the bursitis is a really prominent one or whether it's rather minor we would still give it a shot. And at least from my experience, I'm not sure whether you agree Hans or not, as you said, you're often surprised on how good patient react to it more or less independent of the severity of the bursitis.

Unknown Speaker : 10:53

I think an important aspect is the clinical examination. If you see the patient and the patient has pain on palpation on the lateral or medial aspect, so, in the region of the bursitis, rather than at the dorsal aspect aspect of the tendon itself, then this is a good hint that he will respond. And most of these patients do have a positive for side is in MRI, although you might also see internet engineers lesions, but they do have a bursitis. And if they clinical examination is positive in terms of the bursitis plus we see it resides in the MRI, then we offer this but I think the clinical examination does give a strong hint where is the pain located? Because in the MRI, we regularly see various lesions and the question then is which of the lesions causes pain? Is it all of the lesions or is it only part of the lesions? I think the clinical examination gives us a very good hint and the next step is the infiltration. If the infiltration is positive, but the pain comes back then we do offer minimally invasive surgery for removal of the horse.

Unknown Speaker : 12:01

Yeah, that makes complete sense. I think, obviously, it's gonna be very careful with pairing up the MRI features with the clinical examination and not be not for for a red herring as what we call it in the UK, which, which means focusing on the incidental finding, which is very little relevance to the patient. So I completely agree, you've got to make sure that those two match up.

Unknown Speaker : 12:22

This is very true for the bony spur as well. I mean, we see a lot of those Haglund exostosis, how they are regularly called on x rays taken due to an ankle sprain or whatever. So this is not necessarily a pathological situation.

Unknown Speaker : 12:37

Yeah, I think it's the same with degeneration of the Achilles tendon. If you look at the figures we have for Achilles tendon ruptures, we obviously going to see him with male patients at around the age of 40. If you look at the MRI, most often they do have degenerative changes in their tendons, so it is more or less acute on chronic when they experience some sort of degeneration. Same for the haglund exostosis. So this may be physiological at a certain age at least. So do you see that you're you're not doing the injection yourself back in the days when you did? Did you also do PRP, or anything else that you would offer the patient?

Unknown Speaker : 13:13

No. So when I used to have access to ultra stylistic ultrasound is when I was working in the National Health Service. And things like PRP aren't provided. I have not come across it in the public sector. It's something I've looked into in the private sector, but I think it comes down to business decisions really, and making it cost effective with private health care models here in the UK. So I think that's a barrier for offering PRP. And the evidence is a bit shabby.

Unknown Speaker : 13:43

I fully agree. I was about to say there's, I mean, there's some RCTs to my knowledge showing no effect of PRP, specifically the Achilles tendon, it's different. I mean, you have to differentiate, I think between every tendon but for the Achilles tendon, To my knowledge, there is no good data that PRP injection is really helping.

Unknown Speaker : 14:05

That's my current understanding. So no, I haven't dabbled with PRP for any foot problems as of yet.

Unknown Speaker : 14:11

That's, again, interesting. That's a very cultural thing. I believe in the US, for example, they do it a lot. They put it everywhere, and they are convinced it helps. But a surgeon is convinced it might help. I don't know,

Unknown Speaker : 14:24

Maybe it's not too much culturable. It might have a financial aspect as well.

Unknown Speaker : 14:31

But I think what becomes very clear in our discussion is it is very important to differentiate the different pathologies underlying the insertional tendinopathy is not the same. But there's different pathologies, which respond differently to non operative treatment and which can be addressed completely different surgically. So that's, I think, very good point. We found in our discussion that it's very simple. portant to differentiate the different underlying pathologies,

Unknown Speaker : 15:08

The option we have non operatively are somewhat limited. And we try to have our hands and we all have our we study literature and we have our own thoughts on it. But it comes down to shockwave therapy to maybe sensory clutching exercises and local coordinate injections. And that's about all we got. Yeah, absolutely.

Unknown Speaker : 15:28

From my feeling. And from my understanding, a lot of these patients do quite well with these treatment options. And my feeling is that we only operate the tip of the iceberg because the vast majority gets a lot better using non operative treatment options.

Unknown Speaker : 15:46

Do you prescripe any orthetic Devices?

Unknown Speaker : 15:49

I do, but I'm not as proactive for insertional tendinopathy as I am for some other foot and ankle conditions, and that's partly down because down to the lack of evidence Which doesn't really suggest that hind foot alignment, whether the calcaneus is everted, or inverted that doesn't really seem to be influential. I think when I do prescribe an orthotic, it's usually a patient that has tried other conservative treatments first. And they are either not suitable for surgery or just don't want to have surgery. But they do want to try an alternative. And some people will come to me wanting an orthotic because they've read about it online. Because if you look online, if you type in kilise, tendinopathy, or phottix, will come on as one of those common bullet point options and patients pick up on that and then they come and ask for one. So I'm just very careful to just set expectations correctly and say, we can try this but it may not have that much of an influence on your symptoms. Sometimes it works tremendously well. But I wouldn't say it's consistent. I've seen some other feet where I my gut says yeah, no thought it's gonna work for this patient because their feet are really really flat and a calcaneus is heavily reverted. And if I change that, maybe that will have an effect and sometimes That just hasn't been the case at all.

Unknown Speaker : 17:01

We do have a different feeling about gastroc tightness and its influence on insertional tendinopathy. Do you recommend patients to use any wedges to have a little heel rise to get some tension of that insertion of the Achilles?

Unknown Speaker : 17:14

I do. And I think that when an orthotic works, it works by the fact that you're giving the patient a heel raise, it's not necessarily that it's decreasing foot pronation, I think it's simply that you're giving a heel raise, and you're taking that ankle into a slightly more plantar flexed position. And that is helping with compressive stress around the tendon and the bursar. So I think in all fanatic for this, this problem is, you know, basic terms, you're just a very expensive heel raise, you could give them a five pound raise, and it will probably work just as well. But that's very hard to convince a patient, I can tell the patient you could have a simple heel raise or you can have this fancy customer and a lot of time that

Unknown Speaker : 17:58

This actually seems to be similar in UK as well as Germany.

Unknown Speaker : 18:02

All right. So I think that's been very, very interesting to hear your perspectives and to hear from your experience. And yeah, it's been a great pleasure,

Unknown Speaker : 18:10

Benn, same for me. Great first interview session for our podcast. Absolutely. I'm expected to work out that. Well. I think this will be a common feature for us now.

Unknown Speaker : 18:20

Well, I'm glad you've enjoyed it. It's been it's been a pleasure. And I feel very privileged to be invited on to the podcast. I certainly will do my part in spreading the word of your podcast and posting it around, and hopefully it'll go from strength to strength. Perfect,

Unknown Speaker : 18:33

Benn. Again, thank you very much. And hopefully we got the chance to talk to you again.