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Saturday, December 14, 2013

Achilles Tendon Injury: Email Advice

Hi Dr. Blake,

I wanted to ask your opinion about which direction I should next take with my treatment.

I am a junior college lacrosse player. Last february (9 months ago now) during our preseason my achilles tendon was stepped on during practice. It hurt at the time, I had my trainers look at it but it didn't seem like anything serious so I did the usual treatment options, especially ice and anti-inflammatories. As the season went on, however, the pain got worse and worse. I saw our team doctor who said it was the sheath around my achilles that was inflamed, so he had my trainers place a heel lift in my shoes. But the pain didn't subside and by the end of the season I was placed in a walking boot for 3 weeks to calm the pain down.
Dr Blake's comment: Typically achilles tendinitis is an overuse injury, so your description of being stepped on makes it harder to get a read on. Putting yourself in the Immobilization Phase was the right idea, and it should be coupled with anti-inflammatory treatments as well. 

Over the summer I continued to work out but focus more on weights and cycling/swimming as running continued to be painful (although I did continue to run some). In addition, over the summer I began to do strengthening exercises.
Dr Blake's comment: This was the right order---Immobilize, Cross Train, and strengthen. You were beginning the ReStrengthening Phase of Rehabilitation. 

 When I came back to school in August I continued the strength exercises and lots of stretching but the pain didn't improve. We had a month long fall season and by the end of the month I was back in a walking boot as it was nearly impossible to walk because of the pain. 
Dr Blake's comment: The Immobilization Phase should take you to Pain Levels 0-2. I am not sure of your pain, but it sounds worse. You should stay in this Phase for 2 weeks longer than you think you need to. The restrengthening should continue, as well as the cross training as long as all of this can be maintained in that 0-2 pain scale level. If not, you are just fooling yourself that you are progressing. 

I had an MRI recently and our team doctor said that, while we had thought it was mostly achilles tendinitis, it appeared that while I did have some achilles tendinitis it was mostly bursitis that appears to be the issue.
Dr Blake's comment: Bursitis in front or behind the achilles is a common side effect of achilles tendinitis swelling, or the bursitis was the only source of pain from the beginning. Bursae are fluid filled sacs that collect fluid in the wrong place and act as an irritant to the surrounding tissue. Bursitis elsewhere is treated with cortisone shots, but these are risky close to the achilles. I prefer electrical stimulation with contrasts, or iontophoresis, while going to PT. 

 He checked by strength and noted that my left gluteus (it is the left achilles that is the problem) was weak. My trainers switched up my strengthening program to include more gluteus exercises to improve this.

At this point my doctor also prescribed a topical anti-inflammatory saying that if that didn't work we could consider doing a  cortisone shot into the bursa, but that after the shot I would be in a boot for a month as to avoid rupturing the tendon.

My question to you is that it has been a month and the topical anti-inflammatory doesn't seem to be doing anything (it hasn't helped with the pain or decreased the amount of swelling at all) would you recommend considering the cortisone shot as the next treatment option or do you think that custom orthotics might be able to provide some assistance? Clearly I would like to avoid the cortisone shot.
Dr Blake's comment: Definitely the shot is risky, but I like the idea of a boot for 1 month afterwards. I would not like to do a shot anytime soon. Consider an 8 day Prednisone Burst to reduce the bursitis, while you are doing iontophoresis in PT (transdermal cortisone).

Follow up the oral cortisone with voltaren or another NSAID with a good daily dose. Do Contrast Baths, the best way to reduce bursitis swelling, twice daily and remain in the removable boot for the next month. If you are not significantly better in one month, send me the MRI to look at because something will not make sense. Hope this helps. 

Thank you so much for you advice.
Dr Blake's comment: Tendinitis treatment follows the BRISS formula and The Good Pain vs Bad Pain formula. Memorize well. Good luck!!

Gretchen (name changed)

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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.