Ryan Howard's Problems Continue: Cortisone Shots

It was a tiny pinch, and then relief for Ryan Howard, who had been suffering with a throbbing left heel for several weeks. The cortisone shot flooded into the inflamed bursa sac near the Phillies' Achilles tendon. It was a shot in the dark for both Howard and the Phillies- they hoped the cortisone shot would ease the pain and after a brief rest before the postseason he would return pain free without having compromised his Achilles tendon.
Cortisone shots were developed 63 years ago and are a sports medicine staple because of its anti-inflammatory qualities that provide relief for those suffering with pain. Injections are common in shoulders and elbows, but far less so and more problematic when administered in the Achilles tendon. Medical evidence shows that cortisone shots can damage the surrounding tissue, fray the Achilles tendon, and even trigger a rupture.

So here is the $125 million dollar question: Did a cortisone shot contribute to or hasten Howard's tear? Would it have been wiser to forgo the shot, but have Howard miss the postseason? Did he make the decision or did the Phillies endorse the treatment?
"There wouldn't be any way that you would back me into the corner on anybody (with an Achilles problem) to go ahead and inject them," said Dr. Michael Schafer,an orthopedic consultant to the Chicago Cubs and chairman of the orthopedic surgery department at Northwestern University Hospital. "I've been in practice since 1974 and been involved with sports all my life. When it comes to the risk of an Achilles tendon tear, I'm concerned about cortisone."
Because the drug masks pain instead of addressing the root cause, some fear it encourages patients to overuse the weight-bearing tendon, risking further damage. On October 7, less than three weeks after receiving the shot, Howard completely tore his Achilles tendon. With Howard still out, the Phillies are struggling this season.
Phillies representatives and Howard have not commented on the injury. Howard, a 6-foot 4-inch, 230 pound first baseman had been having problems with his Achilles tendon since August 2010 when he badly sprained his left ankle. It is difficult to tell if Howard was heading down the ruptured tendon path with or without the shot.
Howard and the Phillies apparently knew the risks back in September. When Howard arrived at the Phillies' spring-training site in February, four months after the tendon had been surgically repaired, he indicated to reporters he felt the drug had played a factor in his injury. "I don't know if cortisone leaked in there or not or whatever," Howard said.
The May Clinic lists the following negative side effects: skin of soft tissue thinning around the injection site, and tendon weakening or rupture. The website of Jefferson University Hospital's Rothman Institute, where the Phillies' Ciccotti is listed as director of sports medicine, says that "studies have shown an increased incidence of Achilles tendon rupture after cortisone shots."
Injecting cortisone into the Achilles tendon has become medically taboo, as many doctors believe the heel's compact anatomy and cortisone's degenerative possibilities make it risky.
Howard might be a big man, but the retrocalcaneal bursa, where he was injected, is tiny, the surface no larger than a nickel. However, not every doctor has a problem injecting in the Achilles tendon.
Dr. Rob Raines, an orthopedic specialist with the Cincinnati Reds says "It really depends on your comfort level. It can certainly be done safely. I'm comfortable with the procedure and commonly do inject the Achilles bursa. That's likely because I'm a foot and ankle orthopedic surgeon and feel very comfortable with the anatomy around the Achilles tendon."
Howard is not the first baseball player to ever get a cortisone shot in his Achilles tendon. In 1996, Tony Gwynn had at least one shot near the tendon, even though the San Diego Padres' medical staff did not endorse it. A year later Cincinnati's Barry Larkin had two injections. Both players ended their seasons with partially torn Achilles tendons.
Ultimately, those who are responsible are the team medical staff and the player. We will see how long it takes for Howard to fully recuperate.
If you have problems with your Achilles tendon and do not see a podiatrist, call our Newington, Kensington, or Middletown office to make an appointment.
Craig M. Kaufman, DPM
Connecticut Foot Care Centers
Sports Podiatrist in CT
Podiatrist in Newington, Kensington, and Middletown, CT
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