07/21/2022    Steven Kravitz, DPM

Ultrasonography-Guided corticosteroid Injection vs. Placebo Added to Exercise Therapy for Achilles Tendinopathy (Elliot Udell, DPM)

This is an interesting study, but not necessarily a
"green light" for cortisone injection in the
treatment of Achilles tendinitis. It still should
be used only after conservative treatment, when
heel lifts, stretching, etc. are not effective. If
cortisone injection is used it should be applied
judiciously, not repeated on a regular basis for a
long period of time and short acting steroids are
preferred. Additionally, the degree of tendon
disruption should be considered prior to the use of
cortisone therapy.

Finally, is the lifestyle and the degree of stress
the individual is expected to apply to the Achilles
tendon apparatus post-injection therapy. The two
extremes would be a ballet dancer and a librarian.
The long-term potential negative impact on the
structure intended is of much more concerned with a
ballet dancer and others who are extremely
athletically active. It is not treating Achilles
tendon is treating a patient with an Achilles
tendon.

The use of ultrasound described in this article
should prevent intra tendon injections which would
likely be harmful. Another important point is that
the literature reports that there is increased risk
of tendon rupture following steroid Achilles
injection when there is significant damage to the
tendon prior to the injection therapy.
Additionally, cortisone injection applied
repeatedly, especially on a weekly basis as
described by Dr. Udell, increases risk of tendon
rupture significantly because of cessation of the
healing process.

Inflammation causes blood vessels to expand
allowing immunecells and stem cells to infiltrate
area of damage. New collagen is laid down, tendon
is remodeled, and the injury is repaired. Cortisone
injection stops this process, allowing weakened
tissues remain and over time more vulnerable to re-
injury.

Short-acting steroids should be primarily steroid
of choice for these injections. This allows for a
temporary relief from pain and then for the healing
process to continue. This is most important in the
young athletically active patient.

Resources: Suggested additional reading

1. Foster ZJ, Voss TT, Hatch J, Frimodig A.
Corticosteroid Injections for Common
Musculoskeletal Conditions. Am Fam Physician.
2015;92(8):694-699.
2. Egger AC, Berkowitz MJ. Achilles tendon
injuries. Curr Rev Musculoskelet Med.
2017;10(1):72-80.

3. Childress MA, Beutler A. Management of chronic
tendon injuries. Am Fam Physician. 2013;87(7):486-
490.

Steven Kravitz, DPM, Winston-Salem, NC

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