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Thursday, June 28, 2012

Insertional Achilles Tendinitis: Email Correspondance

Julie is a patient I saw yesterday (name changed for privacy). She has Insertional Achilles Tendinitis and came in for a second opinion. This was the outcome of our visit where I found extremely tight achilles tendons and a prominent heel bone that can get easily irritated by the back of a shoe. Xrays did show some bone spurs which may or may not be part of the pain, but definitely influence how the medical world treats this. 

Both posterior heel spurs (where achilles attaches) and plantar or bottom heel spurs note

Back of Heel Bone Showing Boney Growth

Dr. Blake,
Thanks for taking time to answer questions and share information this afternoon.
Below is my understanding of our discussion. I have a couple of question marks where I would appreciate your confirmation/clarification.
1.       Stretch the calf 4-5x’s/day – I don’t have to try to get it stretch all the way to the bottom where it starts to hurt, don’t do stretches that lower the heel (off the curb), pulling with a towel is OK
2.       Ice 4-5x’s/day  and within 2 hours?? of activity that might aggravate the Achilles
Dr Blake's comment: Definitely a 10-15 minute ice pack within 2 hours of an activity that would predictably irritate it will allow overall less inflammation to collect and cause activity reduction over the next few days. 
3.       Use the heel lifts in the running shoes – icing can be wrapped around foot, it does not need to be localized/massaged.
Dr Blake's comment: I gave her several 1/4 inch heel lifts to use in non heeled shoes, like her running shoes, to take some tension off the back of the heel where the achilles attachs. It also changes the position of the heel against the back of the shoe, and sometimes helps take some pressure off (and sometimes puts more pressure and has to be removed). 
4.       Avoid  explosive (jumping /bootcamp type) activities for a few weeks
5.       Ok to run 4x’s/wk – Sat and Sun can be consecutive days because I will have more time to ice on the weekend
6.       Increase running methodically – flipping run/walk ratio by a minute, if the pain is flared up, I don’t need to go backward on the time flip, just hold off on running until it settles down.
7.       Try the Achilles sock
called Achilles Gel Pad made by Silipos

8.       If I do any strengthening for the calf, such as the calf raises, do it in the evening then ice and rest overnight.
Dr Blake's comment: When strengthening an injured area, at the same time allowing activities which will stress the area, it is important to do the strengthening in the evening 1-2 hours before bed to avoid weakening the muscles/tendons and then having to use them. 
9.       OK to continue ART (Active Release Technique not drawing lessons!!)  with Dr Jess
10.   Request MRI from HMO doctor
Dr Blake's comment: If you read my blog, you probably know I love MRIs. There are too many generalizations being used to treat patients, and MRIs are a great way to individualize the treatment more and understand just what is going on causing this pain. The MRI can help differentiate partial tears, excessive scarring, bursitis, bone edema, and achilles calcifications from the more common plain old ordinary once around the block standard double play achilles tendinitis. 
11.   If an activity hurts, stop, unless the pain is letting up, including running.
Dr Blake's comment: Julie has a high pain level which can work against all rehabilitation programs. Getting her to understand Good vs Bad Pain is crucial. Pain at the start of a workout that looses up and disappears is typically Good Pain. But if the pain comes back while in the workout, you have reached your physiological threshold, and you must stop. Pushing through that pain is BAD!!
12.   Cortisone injection is not recommended, topical might be OK.
Dr Blake's comment: There is four ways to administer cortisone in this patient if we are having trouble getting ahead of the inflammation. Topical with Iontophoresis in Physical Therapy, Short Acting Cortisone Injection, Oral Cortisone in a 7-8 day tapering dose, and Injection of Long Acting Cortisone. Only the Long Acting Cortisone Injection could produce some series damage including tendon rupture, but the other 3 must accompany 2 weeks off athletics which stress the tendon. 
13.   OK to check back via e-mail in a couple of weeks
A couple of other questions I did have are:
1.       If I have flared it up, do you have any concerns with taking some Ibuprofen for inflammation?
Dr Blake's comment: Ibuprofen is fine for flareups, just never take so you can mask pain before working out. 
2.       Do you think there is any benefit to using products, such as BioFreeze?
Dr Blake's comment: I think biofreeze or topical voltaren gel (by Rx) or Flector patches (by Rx) or zyflamend (OTC) are great adjuncts to the above treatments. 

Thanks! Julie


  1. Hello Dr. Blake,

    I really appreciate your blog!

    I seem to be in the same boat as Julie. For the last eight months I have had what appears to be insertional achilles tendinitis. A recent x-ray shows spurs very much like your patient's growth in the back of the heel where my pain is localized. I don't have any pain anywhere else around that spot and there is little noticeable swelling. Were you able to ultimately determine if indeed it was the spur that was the main catalyst for your patient? If so, did the treatment protocol stay the same? Lastly, I understand that few patients elect for surgery for something like a spur but I don't know if matters where the spur is either. Are some locations (like the back of the heel) more problematic?

    Thanks for giving me hope!

    1. Definitely the spurs in the back of the heel, not under, seem to need surgery more often. An MRI is crucial at evaluating the been swelling in the area, and many times the inflammation in so bad, that 3 months in a removable boot is what is needed. You can never be sure it is the spur alone causing the problem, which makes me hesitant recommending surgery for these. I would definitely create a pain free environment for 3 months before considering this surgery. Rich


Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.