Heel Bursitis Injection near the Achilles Tendon: Email Advice

http://www.drblakeshealingsole.com/2010/05/cortisone-shots-thought-process-behind.html

Hi, thanks for the great post (regarding the thought process around cortisone shots) and all the responses to comments which I've read with great interest. I had a cortisone shot yesterday into heel bursitis (also known as retro-calcaneal bursitis when it is near the achilles tendon). Doc went through the achilles at one stage (I was led to believe) but I was very clear prior in requesting he be cautious in relation to the tendon given a history of prob's and utter paranoia about the possible consequences. Wasn't told whether short or long but since it had the anaesthetic (which took good effect), I'm guessing long. The ultrasound showed a pretty gnarly achilles tendon and lots of old scar tissue on calf including a probable tear of the plantaris tendon(???). I have always dealt with a degree of pain which makes me even more nervous about resuming high impact as I may not have a great sense of any pain beyond the norm. Anyway, my sport is squash at a high level, which is obviously pretty ballistic. I conclude from this post and others I must endure 2 weeks of no weight bearing or ballistic cardio, (maybe cycling without raising from seat) , then building from slow to faster running. Any views on sprints and bursts of fast stop start? When and how do you recommend that be started? Am for once willing to be conservative and would welcome any thoughts. Thanks in advance! 

Dr Blake's response:

     First of all, you have a 95% chance that if you are smart over the next several weeks, and then give yourself 4 more weeks to gradually return to activity, you will be fine in regards to any potential damage from the shot. With your history however of a pretty gnarly achilles, with lots of scar tissue (which is always causing some inflammation), etc, and some inflammation in the area that devitalizes the achilles (any tendon), you are at risk of someday hurting it. Hard to know the odds/never really been studied. 

    I would look at this return to full activity as a 6 week journey. The next 2 weeks should be walking, biking without getting off the seat, swimming without pushing off the wall, elliptical without lifting your heel off the plate. Of course, review the BRISS protocol for tendinitis for any other recommendations regarding anti-inflammatory, stretching, biomechanics. Especially please avoid negative heel stretches. 

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

   The second 2 week period is your return to running. Try running every other day, with no hills or sprints. Run 2-3 miles each time just to test how the tendon feels post shot. On the days off running, continue your other cross training. 

   The third 2 week period is your return to squash. Continue every other day, ice after, and start easy with several days of simply hitting. A 3rd and 4th squash workout could be with a partner designed not to be competitive, but gently putting more stress on the tendon. I wish you luck and remember "handball is the real man's game."  

Achilles Tendinitis: Avoid Cortisone Injections

This was a comment posted today on 6/28/13.

First I want to say that I've had Achilles tendonitis in both ankles for the past 5 years. I've had cortisone injections every 6 months for the first 2 years from my local Doctor then went to a Physiotherapist and had 6 months of Shock Wave treatments that didn't help.

Dr Blake's comment: Please try to avoid any type of cortisone injection around the achilles tendon. I am so hopeful that ultrasound guided injections will be the wave of the future, but it will take many years to prove that any injection of cortisone around the achilles tendon is not potentially dangerous. Remember health care providers: do no harm. Use physical therapy, acupuncture, body work, orthotics, stretching, strengthening, etc to help the achilles. 

 I then went to a Specialist and received more injections which only helped for about a month each time and then I was back again for more. Then on the 24th September 2011 I sprained my ankle as I was getting out of bed - yes, before I even touched the floor with my foot. I heard a very loud crack and it hurt really bad - even my husband heard it! It started swelling and aggravated my Achilles tendonitis to the point where I couldn't wear my shoes.

Dr Blake's comment: This is probably a partial tear of the tendon causes or aggravated by the cortisone. 

 I had to buy a pair the next size up if I wanted to go somewhere. It stayed very sore and swollen for months until I had a intensive set of cortisone injections in February 2012. It helped (until now) and the ankle swelling and tendonitis went away but I still have a strange swelling on the top of my foot. It starts where my toes join and then goes up the foot almost to my ankle. It swells and hurts more if I'm on my feet a lot or even just a few hours so I'm going to try your hot and cold bath method to see if it helps.

Dr Blake's comment: This was a comment from the contrast bathing post.

I still have the Achilles tendonitis (in both ankles now again) and was referred back to a different Physiotherapist. After 5 treatments he said I had too much inflammation in my body and couldn't treat me - the more he and I worked on it, the worse it got. The strange thing is, all my doctors etc. have told me doing The Negative Heel Stretch is the only way it will help it but in one of your videos, you say they should be avoided.

Dr Blake's comment: Here is the video associated to that comment.

 I've tried doing them (because my doctors have told me) but I had excruciating pain and had to stop. It only makes my problems worse and for some reason they don't believe me. Anyway, I'm going to follow your advice with the calf, ankle and foot stretching instead and hope it works.

Dr Blake's comment: Definitely push to get an MRI so that we can analyze the 3D of the tendons. Please stay away from cortisone and let the MRI put us into a specific direction.