Joe A Shaw PA-C - 1/22/2008

Question
QUESTION: I am a 42 yo runner who runs about 60 miles per week and who has had Achilles Tendonitis about 5 times in the past 6 years and have also had a few foot injuries (all to the same foot/leg). The last time I injured my Achilles was about 4 months ago. I was put on Anti-inflammatories for about 8 weeks. After no results, I went back and the Corpsmen (I am in the Marine Corps)who put me on Tramadol and 1000 mg/day of Naprosyn. I took the Tramadol for about 1 week and stopped taking it as it did nothing other than make me drowsy. X-rays show calcaneal heel spurring. A civilian DPM has made custom orthotics for me and has said that they will make my feet feel much better and my Plantar Fascia and Achilles should stop hurting and I should have several more years of running ahead of me. How likely is this? I have not received them yet, but am puzzled as to how they will actually help when sometimes me heel just aches without doing anything. I am doing the stretching exercises. Is there anything else I should be doing? How about ultrasound therapy? Is that an option? Any information you could provide would be greatly appreciated. Thanks.

Don

ANSWER: Don,
First off thank-you for serving our country!
60 miles a wk?? that's a lot,that's over 3,120 miles a yr. I don't think you will get much relief with the oral meds, but I would take them at night to help with the throbbing pains. Achilles tendonitis and plantar fasciitis are hard to treat in runners cause they never want to do what they need to do...mainly stop running for a while at least. You get a picture of microscopic fiber tears that re-heal and form scar tissue,then you run and tears occur again,then scar tissue etc...for AT you do need arch supports and heel lifts and leg,calf,hamstring stretches. I would advise to stop all running,or cut back by 75%..no hills,banks etc..Some Drs use hyaluronidase (Wydase) to help the tendon regain its gliding movement within the sheath(this is a off label use) The medicine is injected along the tendon sheath (NOT in the tendon)
PF is often Tx'd with cortisone injections,orthotics and night splints.
Hope this helps
J.Shaw PA-C

---------- FOLLOW-UP ----------

QUESTION: Thank you. I have not been able to run since Sept. as I am waiting(impatiently)for it to heal. I have normal to high arches and wear orthotics, but am waiting for the custom ones to come in. Again, the DPM says that he would like for me to try them first and is reluctant to give a cortisone injection until I try the custom orthotics for a while as he would rather not weaken the tendon.  Just curious that now that I have PF, is this something that I will always be prone to, or is it possible to go away for ever? Thanks again for your help.

Answer
I would say that you will be more prone, as we age this also works against us. If you have not been running since sept and you are no better, that is disappointing. I always ask patients what is your pain level 1-10, 10 being the worse 0 being no pain, then this will guide you in your treatment plan...if you are still in the 8-9 range after 4 mos with walking then I might consider a cortisone injection..if your pain is a 3-4 then I probably wouldn't. DPM's and MD's have a little different philosophy..I would probably seek out an orthopedist who specializes in feet/ankle conditions, if these orthotics don't help. I have read articles by Brian Bowyer MD (who is a jogger)I will provide a link to an association that he has written articles for. You have to register to get all the articles but it is free. It would be a good resource for you on other things as well. Bone spurs are present in 30% or more of people w/o any kind of heel pain, so you have to be leery if he is attributing your heel pain to just spurs. Also cortisone injections have been shown to improve pain in < 6 mos,but no real difference at 1 yr.(but that 6 mos you may be able to get over the hump with some good rehab etc..) "Shock wave" therapy has been approved by the FDA for PF, but I don't think it is what they had hoped for...some have had great response, others have not.
http://www.americanrunning.org/displayindustryarticlelists.cfm?industrytopicnbr=