Painful Posterior Heel: Lateral Heel X-ray for both sides

Right Heel

Left Heel

I hope you can tell it is the right heel that hurts! I have ordered an MRI and CT scan. Rich

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 Tendon Partial Tear MRI Images

This patient presented with a 9 month history of pain in the achilles tendon area. There was no incident of acute pain, however the pain did come on during a long run. The patient continued to finish the 10 mile run, but knew that the achilles was a problem. The MRI (now 9 months post injury) shows surrounding swelling (white regions) and over 50% of the body of the tendon showing changes. The achilles tendon should be solid black, if healthy, in this imaging like the less than 50% on the right side. Within the injured part of the tendon, while the healing goes on, the tendon is part swelling, part tendon, part scar tissue, part stuff that makes it take on an irregular appearance. It is 50% unhealthy. 

A different image of the above tendon which does not highlight swelling. In this image the tendon does not look as bad. This is a T1 image where the above is a T2 image. 

There the side view of a T2 image showing the body of the tendon looking unhealthy (you want solid black). 

Another side view of the achilles with T2 weighting showing the area of partial rupture and the healing process. The central area would look very white if this image was within 2 weeks of the actual injury.

A final side view through the more normal 50% of the tendon showing swelling in front of the tendon, a little tear within the tendon, but overall a very healthy part of the tendon. The swelling in front of the achilles is called a retrocalcaneal bursitis.