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
Visit our website, friend and like our page on Facebook, and follow our tweets on Twitter. 

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Ryan Howard and His Achilles Tendon

After his Achilles tendon rupture last October, Ryan Howard was on track to rejoin the Philadelphia Phillies this May but a serious infection near the healing tendon required surgery, putting off the first baseman's return for a while longer.

The Phillies told Howard to rest and he has not been seen at the team's complex. There is no estimate as to when he will return to practice.
"We immobilized him," Amaro said, "just because our main priority is to get the infection out of there." Amaro added that Howard is taking a strong dose of antibiotics to remove the infection, which can take anywhere from 7 to 10 days to leave his body.
An Achilles tendon rupture like Howard had is serious business.
A tendon is a band of tissue that connects a muscle to a bone. The Achilles tendon runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the "heel cord," the Achilles tendon facilitates walking by helping to raise the heel off the ground.
An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon and cause the tear. An injury to the tendon can also result from falling or tripping.
Achilles tendon ruptures are most often seen in "weekend warriors"- typically middle-aged people participating in sports in their spare time. Less commonly, illness or medication, such as steroids (hmm...) or certain antibiotics, may weaken the tendon and contribute to ruptures.
A person with a ruptured Achilles tendon may experience one or more of the following:

• Sudden pain (which feels like a kick or a stab) in the back of the calf or ankle- often subsiding into a dull ache.
• A popping or snapping sensation. 
• Swelling on the back of the leg between the heel and the calf.
• Difficulty walking (especially uphill or upstairs) and difficulty rising up on the toes. 

These symptoms require prompt medical attention to prevent further damage. Until the patient is able to see a doctor, the R.I.C.E. method should be used (Rest, ice, compression, and elevation).
In diagnosing an Achilles tendon rupture, the foot and ankle surgeon will ask questions about how and when the injury occurred and whether the patient has previously injured the tendon or experienced similar symptoms. The surgeon will examine the foot and ankle, feeling for a defect in the tendon that suggests a tear. Range of motion and muscle strength will be evaluated and compared to the uninjured foot and ankle. If the Achilles tendon is ruptured, the patient will have less strength in pushing down (as on a gas pedal) and will have difficulty rising on the toes.
The diagnosis of an Achilles tendon rupture is typically straightforward and can be made through this type of examination. In some cases however, the surgeon may order a MRI or other advanced imaging tests.
Treatment options for an Achilles tendon rupture include surgical and nonsurgical approaches. The decision of whether to proceed with surgery or nonsurgical treatment is based on the severity of the rupture and the patient's health status and activity level.
Nonsurgical treatment, which is generally associated with a higher rate of re-rupture, is selected for minor ruptures, less active patients, and those with medical conditions that prevent them from undergoing surgery. Nonsurgical treatment requires the use of a cast, walking boot, or brace to restrict motion and allow the torn tendon to heal.
Surgery offers important potential benefits. Besides decreasing the likelihood of re-rupturing the Achilles tendon, surgery often increases the patient's push-off strength and improves muscle function and movement of the ankle.
Various surgical techniques are available to repair the rupture. The surgeon will select the best procedure suited to the patient.
Following surgery, the foot and ankle are initially immobilized in a cast or walking boot. The surgeon will determine when the patient can begin weight-bearing.
Complications such as incision-healing difficulties, re-rupture of the tendon or nerve pain can arise after surgery.
Whether an Achilles tendon rupture has been treated surgically or nonsurgically, physical therapy is an important component of the healing process. Physical therapy involves exercises that strengthen the muscles and improve the range of motion of the foot and ankle.
Craig M. Kaufman, DPM
Sports Podiatrist in CT
Podiatrist in Newington, Kensington, and Middletown CT
Visit our website, friend and like our page on Facebook and follow our tweets on Twitter

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