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I have a number of patients with posterior heel pain with a confirmed diagnosis of retro-calcaneal bursitis via MRi and US. I know there is considerable debate with regards to injectable corticosteroids near the achilles tendon but i have injected a number using high resolution ultrasound combined with orthoses with a good success rate!.
Hi Andy,
I don't use this modality (cortisone) myself, although it is used in conjunction with my orthoses on high-profile soccer players (who need to be fit "yesterday").
My observations are that targetting with ultrasound gives a far better chance of hitting the mark, allowing less cortisone to be used, and less risk of adjacent tissue trauma :)
That said, it would be interesting to examine if condition resolution was much better than with orthoses alone.
Does anyone know of any research on this topic?
Cheers,
David
hi,
in the us,cortisone injections in the retrocalcaneal bursal area are considered to be against standard of care.considering our current malpractice environment it is rarely attempted.
however,i have heard of some practitioners attaining success utilizing other non-steroidal cocktails.i wonder if anyone knows anything about this sort of treatment.
I think it is fair to say that the overall consensus injecting directly into the achilles tendon is contrainidicated however i have seen it done!. There are a number of papers but i am not sure about RCT's. There is also debate here in the uk about injecting the retro calcaneal burase which is why i only use it in intractable cases using US guidance. However i would welcome any further opinion on this.
Clinical anatomy of the retrocalcaneal bursa.
Kachlik D, Baca V, Cepelik M, Hajek P, Mandys V, Musil V, Skala P, Stingl J. Surg Radiol Anat. 2008 Jun;30(4):347-53.
Quote:
The goal of the study was to perform a detailed anatomical description of the retrocalcaneal bursa (RB). Its morphological arrangement was studied on 10 fresh and 30 embalmed lower extremities by microdissection and light microscopy. The RB was present constantly and in all the cases contained 1-2 cm long synovial fold, beginning on the upper wall of RB and distally interposed between the anterior surface of the Achilles tendon and the posterior surface of the calcaneal tuberosity. The volume of RB was 1-1.5 ml. The histological analysis confirmed that the inner surface of the superior and posterior wall of RB have been covered by unilayered synovial membrane, projecting into synovial villi of different shapes and sizes. In the ceiling of RB, delicate fascicle of skeletal muscle fibers was discovered, radiating distally into the regularly present synovial fold. The whole bottom of RB has been covered by 200-500 microm layer of fibrous cartilage into which the calcaneal tendon attached. The cartilagineous layer continued anteroproximally to cover the whole bursal surface of the calcaneal tuberosity, where the thickness of the cortical bone was reduced on mere 50 microm. The obtained results can be used in the improvement of the differential diagnostics and therapy of diagnostics and therapy of the retrocalcaneal bursitis as well as of other kinds of achillar enthesopathies and heel pain.
In my experience: When a patient has failed to respond any other way (PT, Orthotics, NSAI's, etc....) and the next treatment is surgery, I do inject a small amount of cortisone.
I do on occasion get rather good results, at which point I inform the patient that I am not opposed to giving them UP TO 2 injections per year if that will keep them comfortable.
As I'm sure you know there is quite a variation in what the underlying pathology is and what exactly is causing the pain. I do not inject the tendon proper and I do not get at the actual attachemnt of the achilles to the os calcis.
Peritendon or intrabursae injections seems to work with some regularity. SOme patients do well long term, others do not.
When there is obvious retrocalcaneal spurring with enlarged superior angle, surgical debridement can be successful.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Retro-calcaneal bursae
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