Tendinitis and the road to rupture - the pitfalls of cortisone

June 15, 2015

I started having Achilles tendon pain and inflammation around the time I ran the Marine Corps Marathon in 2007.  I was able to manage the intermittent pain and swelling with NSAIDS, especially Motrin. The tendinitis came and went over the next few years, increasing with my level of activity.  I stopped doing several longer runs in favor of 5K’s and 5 milers and I noticed as my training miles increased, so did the frequency and intensity of my Achilles pain.  In addition to NSAIDS I used compression socks, but nothing really gave me very good relief.

In Fall of 2011 I was training for a marathon and the right tendon really flared up, to the point that it was impeding my workouts and I could feel nodules.  I went to my primary medicine physician and he referred me to a physiatrist at a local orthopedic medicine group.  The physiatrist (an MD specializing in rehabilitation and pain management) said that I was stuck in a cycle of inflammation, and I needed to get that inflammation under control to get my pain under control.  She prescribed 800mg Motrin 3 times per day (the max dosage) and the use of Voltaren Gel, a prescription anti-inflammatory.

I continued to train and to use the anti-inflammatories, but my right Achilles tendon in particular presented severe tendinitis.  After a few months of anti-inflammatories, my physiatrist suggested a cortisone injection to get the swelling under control.  She warned me that these injections were associated with Achilles Tendon Rupture (ATR) and told me that I would have to lay off any exercise for a few weeks after the injection.  She also told me that she could not inject directly into the tendon, just around it.  We went ahead with the injection and within a few days my inflammation was gone and I felt fine.  I laid off of running, but I was feeling completely normal post-injection for the fist time in years.

About a month after my first injection, I was out in the yard splitting wood and I tripped over a vine and fell, hyper-extending my right Achilles tendon.  Immediately I felt the swelling and inflammation flare up again, and about a week later I went back to the physiatrist and I asked her for another cortisone injection, which she gave me.  Following the second injection I took a nice layoff over the holidays, and in early 2012 when I resumed running workouts I was doing fine.

Throughout 2012 and 2013 I picked up my mileage, sometimes with sore Achilles tendons and sometimes not.  My right was always more sore than my left, and had the nodules that I could feel about mid-length.  In 2013 I ran the Army Ten Miler here in Washington DC and felt great, then in Spring of 2014 I ran the Rock and Roll DC Half-Marathon and felt very good doing it.  I continued training in 2014, with intermittent Achilles tendinitis plaguing me, and treating it with lots of anti-inflammatories.

In October 2014 I ran the Army Ten Miler in Washington DC.  I had been busy and had not done as much distance work as I should have, but I gutted it out and ran the race with a great time, close to my personal record.  After the race, my Achilles tendonitis returned with a vengeance, particularly in my right Achilles tendon.  In retrospect, running a ten mile race without the proper training base was a good recipe for injury.  I went back to the physiatrist and I explained what I was experiencing and I told her that I wanted another cortisone shot since they had worked for me before.  She again warned me of the association between cortisone shots and ATR rupture, but said that this would only be about my third shot in three years, and she shot me up again in mid-November, 2014.

After my cortisone injection in November 2014 I felt great - the swelling went down and I went back to daily 3 mile training runs.  I was fine for about six weeks, and then in early January, 2015, I had a twinge in my right Achilles after a run.  It got worse, and developed into a serious case of tendinitis.  I went back to the physiatrist and she told me to rest, ice, and use anti-inflammatories.  I stopped running and instead switched to using and exercise bike and and elliptical trainer, which didn’t put as much strain on my Achilles.  Since the last cortisone shot only gave me about 6 weeks of relief she ruled that out as an option for additional treatment.

On Valentine’s Day 2015 I went to the gym at lunch time and did a vigorous workout on the elliptical trainer.  Afterwards, my right Achilles flared up and for the first time seriously impaired my walking - I had suddenly developed a limp due to a sharp pain in my right Achilles.  I continued to limp around, as I had some international travel to do, and my limp and the pain grew worse.  Around the beginning of March 2015 I awoke one morning to find a hematoma under my skin around my right heel.  This, coupled with increasing pain, lead me to go to the ER.  The ER doc examined me and told me that my Thompson test was good - no rupture, but he was concerned about the pain, the nodules, and the bleeding.  He splinted me and sent me to an orthopedic surgeon in the same practice as my physiatrist.  The OS ordered an MRI and it came back, in mid-March 2015, as a small but moderate partial-thickness tear in my right Achilles a couple centimeters above my right heel.

Now that I had my diagnosis, physical therapy and a walking boot were prescribed for me, which I began immediately.

A footnote - in retrospect, I would never have taken the cortisone injections.  All the literature I can now find, plus my doctor’s own warnings to me, list cortisone injections as a leading contributor to rupture, and I had multiple injections in the area of the Achilles which tore and eventually ruptured.  I think part of the problem is that I went to a pain doctor to manage my tendinitis. In retrospect, I should have consulted an orthopedist. The very first thing my orthopedist told me when he examined me post-tear was "NO MORE CORTISONE!"  I think that someone who sews these things together for a living would have advised me against the injections, although in defense of the physiatrist, she did warn me.  Right before she shot me up.

I was on the road from a tear to a complete rupture - which came not long afterwards.