Injections to treat midportion Achilles tendinosis

NewsBot · Jul 23, 2008

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Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol
Lotta Willberg, Kerstin Sunding, Lars Öhberg, Magnus Forssblad, Martin Fahlström and Håkan Alfredson
Knee Surgery, Sports Traumatology, Arthroscopy (in press)

Abstract Two to three ultrasound (US) and colour Doppler (CD)-guided injections of the sclerosing substance Polidocanol (5 mg/ml) have been demonstrated to give good clinical results in patients with chronic midportion Achilles tendinopathy. This study aimed to investigate if a higher concentration of Polidocanol (10 mg/ml) would lead to a less number of treatments, and lower volumes, needed for good clinical results. Fifty-two consecutive Achilles tendons (48 patients, mean age 49.6 years) with chronic painful midportion Achilles tendinopathy, were randomised to treatment with Polidocanol 5 mg/ml (group A) or 10 mg/ml (group B). The patients and treating physician were blinded to the concentration of Polidocanol injected. All patients had structural tendon changes and neovascularisation in the Achilles midportion. Treatment was US + CD-guided injections targeting the region with neovascularisation (outside ventral tendon). A maximum of three treatments (6–8 weeks in between) were given before evaluation. Patients not satisfied after three treatments were given additional treatment with Polidocanol 10 mg/ml, up to five treatments. For evaluation, the patients recorded the severity of Achilles tendon pain during activity on a visual analogue scale (VAS), before and after treatment. Patient satisfaction with treatment was also assessed. At follow-up (mean 14 months) after three treatments, 18/26 patients in group A and 19/26 patients in group B were satisfied with the treatment and had a significantly reduced level of tendon pain (P < 0.05). After completion of the study, additional treatments with Polidocanol 10 mg/ml in the not satisfied patients resulted in 26/26 satisfied patients in both groups A and B. In summary, we found no significant differences in the number of satisfied patients, number of injections or volumes given, between patients treated with 5 or 10 mg/ml Polidocanol.
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Admin2 · Jul 25, 2008

Related:
Other achilles tendon threads
Other injection therapy threads
Other prolotherapy threads

NewsBot · Mar 18, 2009

Endoscopic treatment of chronic mid-portion Achilles tendinopathy: novel technique with short-term results.
Thermann H, Benetos IS, Panelli C, Gavriilidis I, Feil S.
Knee Surg Sports Traumatol Arthrosc. 2009 Mar 14. [Epub ahead of print]

In this prospective study, we present the short-term clinical results of a novel endoscopic surgical technique for patients suffering from chronic painful mid-portion Achilles tendinopathy. Eight consecutive patients (seven men and one woman, mean age 52 years) diagnosed with chronic painful mid-portion Achilles tendinopathy were included in this study and were treated with endoscopic debridement of the ventral neovascularized area, the peritendineum and the Achilles tendon. Patients recorded the function of the Achilles tendon and the severity of Achilles tendon pain during tendon loading activity, pre and postoperatively in a visual analogue scale. Patient global satisfaction was also assessed in a similar manner. Patients were followed-up for 6 months. All patients experienced immediate postoperative pain relief. In terms of Achilles tendon pain, the median visual analogue score (VAS) increased from 40 (10-60) (preoperatively) to 97.5 (85-100) (last follow-up examination). In terms of Achilles tendon function, the median VAS increased from 22.5 (0-30) (preoperatively) to 90 (80-95) (last follow-up examination). In terms of global satisfaction, the median VAS in the last follow-up examination was 85 (70-95). No postoperative complications were recorded. In conclusion, the short-term clinical results were satisfactory.
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NewsBot · Jan 21, 2011

The effectiveness of prolotherapy in the management of recalcitrant medial tibial stress syndrome: a pilot study
M Curtin, T Crisp, P Malliaras, N Padhiar
Br J Sports Med 2011;45:e1 doi:10.1136/bjsm.2010.081554.8

Objective To study the effectiveness of dextrose prolotherapy in the treatment of recalcitrant medial tibial stress syndrome (MTSS).

Design A prospective case-series.

Setting A London private hospital.

Participants Seven patients: five male and two female; (mean age=36 years+4 months) referred to a specialist tertiary referral centre having failed existing care pathways for MTSS.

Intervention Subjects received a subperiosteal injection containing 15% dextrose solution via a BD spinal needle 22GA 3.5 IN (0.7×90 mm) under ultrasound guidance. Typically a 1 ml volume of the dextrose solution was injected per centimetre of symptomatic area of the tibia using a 20 ml syringe, giving set and three-way tap.

Study period 11/2009–7/2010

Main outcome measures Subjects completed a visual analogue scale (VAS) for average pain (where 10=severe pain and 0=no pain). Scores recorded at baseline, 1, 2 and 4 weeks postinjection and again during telephone follow-up (mean 18 weeks, range 13–36 weeks). Subjects were also reviewed at least once in a follow-up appointment where they also completed a symptom diary. At final telephone follow-up they completed a six-point Likert global improvement scale, and a five-point activity scale.

Results All subjects reported a marked improvement in their symptoms. There was a significant decrease in mean average pain measured by VAS scores at 4 weeks (p <0.05) and 18 weeks (p<0.05) compared to baseline. The median VAS average pain score improvement per subject was 4/10. The median change in activity value at 18 week postinjection follow-up was a score of 4.0 representing a return to a desired level of sport but not to preinjury level. The median Likert global improvement score at 18 weeks postinjection follow-up was 2.0 which represented ‘much improved’ on a six-point scale. There were no adverse events.

Conclusions Dextrose prolotherapy injection resulted in tangible symptom improvement in seven patients with painful recalcitrant MTSS. Controlled trials of this intervention are warranted.
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Kent · Mar 17, 2011

We just had this paper published in this month's edition of the British Journal of Sports Medicine...

Br J Sports Med 2011;45:421-428 doi:10.1136/bjsm.2009.057968

Original articles

Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial

Michael J Yelland1, Kent R Sweeting1, John A Lyftogt2, Shu Kay Ng1, Paul A Scuffham1, Kerrie A Evans1
+ Author Affiliations

1Griffith University, Logan and Gold Coast, Australia
2Active Health QEII, Christchurch, New Zealand

Accepted 28 May 2009
Published Online First 22 June 2009

Abstract

Objective: To compare the effectiveness and cost-effectiveness of eccentric loading exercises (ELE) with prolotherapy injections used singly and in combination for painful Achilles tendinosis.

Design: A single-blinded randomised clinical trial. The primary outcome measure was the VISA-A questionnaire with a minimum clinically important change (MCIC) of 20 points.

Setting: Five Australian primary care centres.

Participants: 43 patients with painful mid-portion Achilles tendinosis commenced and 40 completed treatment protocols.

Interventions: Participants were randomised to a 12-week program of ELE (n=15), or prolotherapy injections of hypertonic glucose with lignocaine alongside the affected tendon (n=14) or combined treatment (n=14).

Main outcome measurements: VISA-A, pain, stiffness and limitation of activity scores; treatment costs.

Results: At 12 months, proportions achieving the MCIC for VISA-A were 73% for ELE, 79% for prolotherapy and 86% for combined treatment. Mean (95% CI) increases in VISA-A scores at 12 months were 23.7 (15.6 to 31.9) for ELE, 27.5 (12.8 to 42.2) for prolotherapy and 41.1 (29.3 to 52.9) for combined treatment. At 6 weeks and 12 months, these increases were significantly less for ELE than for combined treatment. Compared with ELE, reductions in stiffness and limitation of activity occurred earlier with prolotherapy and reductions in pain, stiffness and limitation of activity occurred earlier with combined treatment. Combined treatment had the lowest incremental cost per additional responder ($A1539) compared with ELE.

Conclusions: For Achilles tendinosis, prolotherapy and particularly ELE combined with prolotherapy give more rapid improvements in symptoms than ELE alone but long-term VISA-A scores are similar.

Trial registration number ACTRN: 12606000179538
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NewsBot · Jul 2, 2020

The effect of high-volume image-guided injection in the chronic non-insertional Achilles tendinopathy: a retrospective case series
Torsten Grønbech Nielsen, Lene Lindberg Miller, Bjarne Mygind-Klavsen & Martin Lind
Journal of Experimental Orthopaedics volume 7, Article number: 45 (2020)

Purpose
To evaluate if High-volume Image-guided Injection (HVIGI)-treatment for chronic mid-portion Achilles tendinopathy (AT) improve function and reduce pain at 12-months follow-up.

Methods
Patients with resistant mid-portion AT who failed to improve after a three-month eccentric loading program were included in the study. Maximal tendon thickness was assessed with ultrasound. All patients were injected with 10 mL of 0.5% Marcaine, 0.5 mL Triamcinolonacetonid (40 mg/mL) and 40 mL of 0.9% NaCl saline solution under real-time ultrasound-guidance and high pressure. All outcome measures were recorded at baseline and 12 months. A standardized eccentric rehabilitation protocol was prescribed after HVIGI-treatment. Clinical outcome was assessed with the Victorian Institute of Sports Assessment-Achilles tendon questionnaire (VISA-A) and statistically analyses were performed.

Results
The study included 30 single treatment HVIGI procedures in AT in 28 patients (23 men, 5 women) with a mean age of 45.1 (range 16–63). The mean duration of symptoms before HVIGI was 37 months. The baseline VISA-A score of 50 ± 15 (range 14–74) improved to 61 ± 21 (range 31–94) after 1 year (p = 0.04). Of the 30 AT procedures 10 patients (11 AT) were not satisfied after the initial HVIGI procedure. Of these, 8 patients (9 AT) needed additional HVIGI and two patients needed surgery. Of the remaining 18 patients (19 AT), 10 patients had more than a 10-point improvement in the VISA-A score after 1 year.

Conclusions
In this retrospective case-study, only 10 patients (33%) did benefit of a single HVIGI treatment at 12-months and an 11-point significant improvement was seen at on the VISA-A score.
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NewsBot · Apr 6, 2021

BONE MARROW ASPIRATE CONCENTRATE INJECTION OF THE ACHILLES TENDON IN A COMPETITIVE DISTANCE RUNNER
Kathryn A. Farina, Blake A. Kandah, Nan M. Sowers and Gregory A. Moore
Journal of Musculoskeletal Research

Achilles tendon disorders, including tendinopathy and ruptures, are common among competitive runners. Relatively high complication rates, recurring injuries, and the need to return to sport have led to the use of regenerative medical treatment in tendon disorders in competitive athletes. Biologic therapies, including bone marrow aspirate concentrate (BMAC) injections, have been effective in restoring injured tissue in a limited number of cases. In this case, a collegiate cross country runner with Achilles tendon pain underwent years of failed, non-surgical conservative management. The patient’s MRI demonstrated moderate distal calcaneus tendinosis with high-grade partial thickness tearing of the anterior fibers of the Achilles tendon (50% tear). The patient underwent peritendinous injection of BMAC. Post-procedure MRI demonstrated minimal tendinosis of the distal and lateral margins of the Achilles tendon, and no evidence of Achilles tendon tear. The patient followed a progressive return to running program, ultimately training 40 miles per week with minimal Achilles tendon pain.
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NewsBot · Jul 14, 2021

Outcomes of iliac crest bone marrow aspirate injection for the treatment of recalcitrant Achilles tendinopathy
Wisutthinee Thueakthong et al
Int Orthop. 2021 Jul 13

Background: Achilles tendinopathy is a common cause of posterior ankle and heel pain in both active and sedentary patients. Though the majority of patients respond to first-line non-operative management including activity modification, immobilization, orthotics, and physical therapy with stretching and eccentric strengthening, there is no consensus for patients who fail these treatments. We evaluate the role of iliac crest bone marrow aspirate (BMA) injections as a treatment option for recalcitrant cases.

Methods: A retrospective chart review was conducted of patients with refractory Achilles tendinopathy treated with iliac crest BMA concentrate injection. Symptoms were assessed using the numeric rating system (NRS) pain score at the pre-operative visit and at six, 12, 24, and 48 weeks postoperatively. Post-operative complications were recorded.

Results: A total of 15 patients (15 feet) with recalcitrant Achilles tendinopathy (5 insertional, 8 non-insertional, 2 combined) treated with iliac crest BMA concentrate injections were included in the study. Average age was 53.2 years (range, 25 to 64), average BMI was 27.1 kg/m2 (range, 18.4 to 34.4), and average duration of symptoms prior to BMA injection was 2.3 years (range, 1 to 7). Pre-operatively, average NRS was 6.26 (95% CI, 5.04 to 7.49), with significant improvement at six weeks (mean, 4.26; 95% CI, 2.94 to 5.59; p = 0.04), ten weeks (mean, 4.13; 95% CI, 2.91 to 5.35; p = 0.012), 24 weeks (mean, 3.40; 95% CI, 2.05 to 4.75; p = 0.03), and 48 weeks (mean, 2.60; 95% CI, 1.14 to 4.06; p = 0.007) post-operatively. Overall, there was trending improvement over the 48-week follow-up period, with a mean improvement in NRS of - 3.22 (95% CI, - 1.06 to - 5.38; p = 0.007) at final follow-up. There was no discernable difference between insertional and non-insertional tendinopathy, and there were no incidences of post-operative complications.

Conclusion: Iliac crest BMA appears to be a safe, effective, and potentially lasting treatment option for patients with intractable, insertional and non-insertional Achilles tendinopathy. Patients demonstrated and maintained statistically significant decrease in NRS pain score post-operatively with no complications at the donor or injection site.
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NewsBot · Oct 8, 2021

Outcomes of iliac crest bone marrow aspirate injection for the treatment of recalcitrant Achilles tendinopathy
Wisutthinee Thueakthong, Cesar de Cesar Netto, Apiporn Garnjanagoonchorn, Jonathan Day, Guy Friedman, Harry Auster, Eric Tan & Lew C. Schon
International Orthopaedics volume 45, pages2423–2428 (2021)

Background
Achilles tendinopathy is a common cause of posterior ankle and heel pain in both active and sedentary patients. Though the majority of patients respond to first-line non-operative management including activity modification, immobilization, orthotics, and physical therapy with stretching and eccentric strengthening, there is no consensus for patients who fail these treatments. We evaluate the role of iliac crest bone marrow aspirate (BMA) injections as a treatment option for recalcitrant cases.

Methods
A retrospective chart review was conducted of patients with refractory Achilles tendinopathy treated with iliac crest BMA concentrate injection. Symptoms were assessed using the numeric rating system (NRS) pain score at the pre-operative visit and at six, 12, 24, and 48 weeks postoperatively. Post-operative complications were recorded.

Results
A total of 15 patients (15 feet) with recalcitrant Achilles tendinopathy (5 insertional, 8 non-insertional, 2 combined) treated with iliac crest BMA concentrate injections were included in the study. Average age was 53.2 years (range, 25 to 64), average BMI was 27.1 kg/m2 (range, 18.4 to 34.4), and average duration of symptoms prior to BMA injection was 2.3 years (range, 1 to 7). Pre-operatively, average NRS was 6.26 (95% CI, 5.04 to 7.49), with significant improvement at six weeks (mean, 4.26; 95% CI, 2.94 to 5.59; p = 0.04), ten weeks (mean, 4.13; 95% CI, 2.91 to 5.35; p = 0.012), 24 weeks (mean, 3.40; 95% CI, 2.05 to 4.75; p = 0.03), and 48 weeks (mean, 2.60; 95% CI, 1.14 to 4.06; p = 0.007) post-operatively. Overall, there was trending improvement over the 48-week follow-up period, with a mean improvement in NRS of − 3.22 (95% CI, − 1.06 to − 5.38; p = 0.007) at final follow-up. There was no discernable difference between insertional and non-insertional tendinopathy, and there were no incidences of post-operative complications.

Conclusion
Iliac crest BMA appears to be a safe, effective, and potentially lasting treatment option for patients with intractable, insertional and non-insertional Achilles tendinopathy. Patients demonstrated and maintained statistically significant decrease in NRS pain score post-operatively with no complications at the donor or injection site.
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NewsBot · Nov 30, 2021

Efficacy of high-volume injections with and without corticosteroid compared with sham for Achilles tendinopathy: a protocol for a randomised controlled trial
Peter Malliaras et al
BMJ Open Sport Exerc Med. 2021 Oct 22;7(4):e001136

Introduction: Achilles tendinopathy (AT) is a common and disabling musculoskeletal condition. First-line management involving Achilles tendon loading exercise with, or without, other modalities may not resolve the problem in up to 44% of cases. Many people receive injections. Yet there are no injection treatments with demonstrated long-term efficacy. The aim of the trial is to examine the 12-month efficacy of high-volume injection (HVI) with corticosteroid and HVI without corticosteroid versus sham injection among individuals with AT.

Methods and analysis: The trial is a three-arm, parallel group, double-blind, superiority randomised controlled trial that will assess the efficacy of HVI with and without corticosteroid versus sham up to 12 months. We will block-randomise 192 participants to one of the three groups with a 1:1:1 ratio, and both participants and outcome assessors will be blinded to treatment allocation. All participants will receive an identical evidence-based education and exercise intervention. The primary outcome measure will be the Victorian Institute of Sport Assessment - Achilles (VISA-A) at 12 months post-randomisation, a validated, reliable and disease-specific measure of pain and function. Choice of secondary outcomes was informed by core outcome domains for tendinopathy. Data will be analysed using the intention-to-treat principle.

Ethics and dissemination: Ethics approval was obtained via the Monash University Human Ethics Committee (no: 13138). The study is expected to be completed in 2024 and disseminated via peer review publication and conference presentations.
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NewsBot · Dec 12, 2021

Do High-Volume Injections Affect the Ultrasonographic Neovascularization in Chronic Achilles Tendinopathy? A Randomized Placebo-Controlled Clinical Trial
van Oosten, Claire C. M. et al
Clinical Journal of Sport Medicine: December 9, 2021 - Volume - Issue -

Objective:
High-volume injections (HVIs) are thought to target neovascularization in chronic midportion Achilles tendinopathy (AT), yet the mechanism has not been clarified. Therefore, we aim to evaluate whether a HVI decreases ultrasonographic Doppler flow in patients with chronic midportion AT.

Design:
A double-blind, randomized, placebo-controlled clinical trial.

Setting:
Sports medicine department at a district general hospital.

Patients:
Sixty-two patients with clinically diagnosed chronic midportion AT were included and randomized into the intervention group (HVI-group, n = 30) and placebo group (n = 32).

Intervention:
A daily calf-muscle exercise program combined with either (1) a HVI (HVI-group: 50 mL) or (2) a placebo-injection (placebo-group: 2 mL) with a mixture of saline and lidocaine.

Main Outcome Measures:
Primary outcome was the surface area quantification (SAQ) score (%) of the Doppler flow during a 24-week follow-up period. Secondary outcome was the association between SAQ scores and symptoms [Victorian Institute of Sports Assessment–Achilles (VISA-A)]. Outcomes were measured before, directly after, and 1 hour after the injection and at 2, 6, 12, and 24 weeks of follow-up.

Results:
There was no significant between-group difference at 24 weeks [−0.1%; 95% confidence interval (CI), −4.9 to 4.7] or at any of the other time points. Change in SAQ score did not correlate with the change in VISA-A score (P = 0.93).

Conclusion:
A HVI does not affect Doppler flow in patients with chronic midportion AT. Also, changes in Doppler flow were not associated with the clinical outcome. These findings challenge the theoretical basis of a HVI.
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NewsBot · Mar 7, 2022

Dexamethasone Enhances Achilles Tendon Healing in an Animal Injury Model, and the Effects Are Dependent on Dose, Administration Time, and Mechanical Loading Stimulation
Franciele Dietrich-Zagonel, MSc, PhD, Per Aspenberg, MD, Prof, Pernilla Eliasson, MSc, PhD
The American Journal of Sports Medicine March 2, 2022

Background:
Corticosteroid treatments such as dexamethasone are commonly used to treat tendinopathy but with mixed outcomes. Although this treatment can cause tendon rupture, it can also stimulate the tendon to heal. However, the mechanisms behind corticosteroid treatment during tendon healing are yet to be understood.

Purpose:
To comprehend when and how dexamethasone treatment can ameliorate injured tendons by using a rat model of Achilles tendon healing.

Study Design:
Controlled laboratory study.

Methods:
An overall 320 rats were used for a sequence of 6 experiments. We investigated whether the drug effect was time-, dose-, and load-dependent. Additionally, morphological data and drug administration routes were examined. Healing tendons were tested mechanically or used for histological examination 12 days after transection. Blood was collected for flow cytometry analysis in 1 experiment.

Results:
We found that the circadian rhythm and drug injection timing influenced the treatment outcome. Dexamethasone treatment at the right time point (days 7-11) and dose (0.1 mg/kg) significantly improved the material properties of the healing tendon, while the adverse effects were reduced. Local dexamethasone treatment did not lead to increased peak stress, but it triggered systemic granulocytosis and lymphopenia. Mechanical loading (full or moderate) is essential for the positive effects of dexamethasone, as complete unloading leads to the absence of improvements.

Conclusion:
We conclude that dexamethasone treatment to improve Achilles tendon healing is dose- and time-dependent, and positive effects are perceived even in a partly unloaded condition.

Clinical Relevance:
These findings are promising from a clinical perspective, as the positive effect of this drug was seen even when given at lower doses and in a moderate loading condition, which better mimics the load level in patients with tendon ruptures.
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NewsBot · Apr 11, 2022

Orthopaedic Journal of Sports Medicine
High-Volume Image-Guided Injections in Achilles and Patellar Tendinopathy in a Young Active Military Population: A Double-Blind Randomized Controlled Trial
Robert M. Barker-Davies, PhD*, Polly Baker, MA, James Watson, MSc, ...
April 8, 2022

Background:
Chronic Achilles and patellar tendinopathy are a significant burden in physically active populations. High-volume image-guided injection (HVIGI) proposes to strip away associated neovascularity, disrupt painful nerve ingrowth, and facilitate rehabilitation.

Purpose:
To investigate the efficacy of HVIGI with and without steroid relative to placebo.

Study Design:
Randomized controlled trial; Level of evidence, 1.

Methods:
A total of 62 participants were recruited between May 25, 2016, and March 5, 2020. Participants were men aged 18 to 55 years with Achilles or patellar tendinopathy of at least 6-month chronicity that had not improved with nonoperative management (including physical therapy and shockwave therapy), with ultrasound evidence of neovascularization, tendon thickening, and echogenic changes. They were assigned to the following groups: control (3 mL of subcutaneous 0.5% bupivacaine), HVIGI (10 mL of 0.5% bupivacaine and 30 mL of normal saline, ultrasound-guided between tendon and underlying fat pad), or HVIGI with steroid (HVIGIwSteroid; 0.25 mL of 100 mg/mL hydrocortisone). Clinicians and assessors were blinded. All participants were supervised through a pain-guided progressive loading program for 6 months postinjection. The main outcome measures were the Victoria Institute of Sport Assessments (VISA) for Achilles and patellar tendinopathy and the visual analog scale (VAS) for pain at 6 months postinjection.

Results:
The VISA score improved by a mean of 22.8 points (95% CI, 10.4-35.3 points; effect size [ES], 1.51) in the control group (n = 21), 18.6 points (95% CI, 9.1-28.0 points; ES, 1.31) in the HVIGI group (n = 21), and 18.5 points (95% CI, 3.4-33.6 points; ES, 0.88) in the HVIGIwSteroid group (n = 20). VAS pain improved by a mean of 15 points (interquartile range [IQR], –38.75, 8 points; ES, 0.39) in controls, 13 points (IQR,–34.0, 3.75 points; ES, 0.47) in the HVIGI group, and 27 points (IQR,–38.0, –1.0 points; ES, 0.54) in the HVIGIwSteroid group. The main effects were significant for time (P < .001) but not group (P ≥ .48), with no group × time interaction (P = .71). One participant was lost to follow-up from each group, multiple imputation was used for missing data points. No adverse events occurred.

Conclusion:
Study findings did not demonstrate superiority of HVIGI over control injection.
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NewsBot · Jul 17, 2022

Effect of Ultrasonography-Guided Corticosteroid Injection vs Placebo Added to Exercise Therapy for Achilles Tendinopathy
A Randomized Clinical Trial
Finn Johannsen et al
JAMA Netw Open. 2022;5(7):e2219661. doi:10.1001/jamanetworkopen.2022.19661

Key Points
Question Compared with placebo injections, do ultrasonography-guided corticosteroid injections improve outcomes in adults with Achilles tendinopathy managed with exercise therapy?

Findings In this randomized clinical trial of 100 patients, statistically and clinically relevant improvement was found in the group receiving exercise therapy combined with corticosteroid injections.

Meaning In this study, a combination of exercise therapy and corticosteroid injection was more effective than exercise therapy and a placebo injection in the treatment of patients with long-standing Achilles tendinopathy.
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Importance Corticosteroid injections and exercise therapy are commonly used to treat chronic midportion Achilles tendinopathy, but the evidence for this combination is limited.

Objective To investigate the effect of corticosteroid injection and exercise therapy compared with placebo injection and exercise therapy for patients with Achilles tendinopathy.

Design, Setting, and Participants This was a participant-blinded, physician-blinded, and assessor-blinded randomized clinical trial of patients with Achilles tendinopathy verified by ultrasonography. Assessment of pain and function were conducted at baseline and at 1, 2, 3, 6, 12, and 24 months. Patients were recruited from a university medical clinic and a private rheumatology clinic in Denmark between April 2016 and September 2018. Data analysis was performed from June to September 2021.

Interventions Corticosteroid injection and placebo injection were performed with ultrasonography guidance. Exercise therapy was based on previous trials and consisted of 3 exercises done every second day.

Main Outcomes and Measures The primary outcome was the Victorian Institute of Sports Assessment–Achilles (VISA-A) score (range, 1-100, with 100 representing no symptoms) at 6 months. Secondary outcomes included pain measured using a 100-mm Visual Analog Scale for morning pain and pain during exercise (with higher scores indicating worse pain), global assessment (Likert scale), and tendon thickness.

Results A total of 100 patients were included, with 52 randomized to placebo (mean age, 46 years [95% CI, 44-48 years]; 32 men [62%]) and 48 randomized to corticosteroid injection (mean age, 47 years [95% CI, 45-49 years]; 28 men [58%]). Patients in the 2 groups had similar height (mean [SD], 177 [8] cm), weight (mean [SD], 79 [12] kg), and VISA-A score (mean [SD], 46 [18]) at baseline. The group receiving exercise therapy combined with corticosteroid injections had a 17.7-point (95% CI, 8.4-27.0 points; P < .001) larger improvement in VISA-A score compared with patients receiving exercise therapy combined with placebo injections at 6 months. No severe adverse events were observed in either group, and there was no deterioration in the long term (2-year follow-up).

Conclusions and Relevance Corticosteroid injections combined with exercise therapy were associated with better outcomes in the treatment of Achilles tendinopathy compared with placebo injections and exercise therapy. A combination of exercise therapy and corticosteroid injection should be considered in the management of long-standing Achilles tendinopathy.
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NewsBot · Feb 27, 2023

Histological and Biomechanical Effects of Local Anesthetics and Steroids on Achilles Tendon: A Study in Rats
Baris Kafa et al
Source

Background:
Peritendinous injection of local anesthetics, alone or in combination with corticosteroids, is widely used in the treatment of tendinopathies. Toxicity of local anesthetics has been demonstrated in many cells, including myocytes, chondrocytes, and neurons. Bupivacaine and lidocaine are known to have time- and dose-dependent cytotoxicity in these cells. The effects of these agents on the tendon remain unknown.
Purpose:
To show histological and biomechanical effects after the injection of different local anesthetics and steroids, both single and combined, at different concentrations into the peritendinous sheath of rat Achilles tendon.
Study Design:
Controlled laboratory study.
Methods:
In the study, 100 rats were divided into 10 groups with equal body weights. Inflammation was induced in both Achilles tendons of each rat by means of the ball drop technique; 7 hours later, injections were made into the peritendinous sheaths of both Achilles tendons using lidocaine, bupivacaine, and dexamethasone as appropriate for the rat’s group. At the end of the first week, the right Achilles tendons of the rats were removed for histological study. Left Achilles tendons were evaluated in terms of biomechanics.
Results:
Histological findings demonstrated that the group with the most toxicity to the tendon was the group that received injection of dexamethasone alone. The groups with the least toxicity were those receiving dexamethasone combined with low- or high-dose bupivacaine. Biomechanical findings showed that the experimental groups had similar results to each other with the exception of the groups receiving 0.25% bupivacaine alone and dexamethasone alone, in which tendons revealed higher tensile strength.
Conclusion:
Local anesthetic and steroid applications have different histological and biomechanical effects on the tendon. Although the dexamethasone-injected group was the most affected in terms of histology, these changes could not be demonstrated biomechanically.
Clinical Relevance:
In future clinical studies, the effect of steroids on the tendon should be investigated more comprehensively. Whether biomechanical results overlap with histological results should be investigated further.
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NewsBot · Aug 13, 2023

Terminating Corticosteroid Injection in Tendinopathy? Hasta la Vista, Baby
Journal of Orthopaedic & Sports Physical Therapy

SYNOPSIS: Two recent randomized-controlled trials showed promising results of local corticosteroid injections combined with exercise therapy for Achilles tendinopathy and plantar fasciopathy. Should clinicians go back to using corticosteroid injections to treat tendinopathy? Are corticosteroids back (baby)? In this viewpoint we critically appraise the new evidence and humbly share our clinical reasoning when advising athletes about corticosteroid injections in practice. Our goal is to help clinicians decide what to do and what to recommend to patients. We prioritize the risk for higher recurrence rates and tendon rupture when weighing the reasonable treatment options for tendinopathy, and recommend against using corticosteroid injections. The best systematic review evidence shows that local corticosteroid injections are not effective for tendinopathies after the first few weeks, and produce worse long-term outcomes compared to other treatments. For now, we consider corticosteroid injections remain terminated.
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NewsBot · Feb 11, 2024

Ultrasound-guided injection of the achilles paratenon: A cadaveric investigation
Vincenzo Ricci et al
Foot Ankle Surg. 2024 Jan 20:S1268-7731(24)00024-9

Background: Injections around the Achilles tendon (AT) are commonly performed in clinical practice to manage non-insertional Achilles tendinopathy, but the presence/distribution of the injectate with relation to its sheath has not been assessed specifically. Accordingly, the aim of this cadaveric investigation was to demonstrate the feasibility of Achilles paratenon injection under ultrasound guidance - by confirming the exact needle positioning as well as the dye distribution inside the paratenon lumen.

Methods: A descriptive laboratory study with three human cadaveric specimens (one fresh cadaver and two cadavers embalmed using the Fix for Life (F4L) method) was performed in a tertiary-care academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced inside the Achilles paratenon under ultrasound guidance i.e. in-plane medial-to-lateral approach. With the objective to confirm its correct placement, the needle was kept in situ on the right AT of the fresh cadaver. Likewise, to demonstrate the location of the dye inside the lumen of Achilles paratenon, the other five ATs - four on the embalmed cadavers and one on the fresh cadaver - were injected with 5 mL of green color dye. After removal of the needle, a layer-by-layer anatomical dissection was performed on all three cadavers.

Results: On the right AT of the fresh cadaver, the position of the needle's tip within the Achilles paratenon was confirmed. Accurate placement of the dye inside the paratenon lumen was confirmed in four (80%) ATs, one of the fresh and three of the embalmed cadavers. No spread inside the crural fascia compartment or between the AT and the Kager's fat pad was observed. Herewith, unintentional spilling of the dye within the superficial soft tissues of the posterior leg was reported in the left AT of one of the two embalmed cadavers (20%).

Conclusions: Ultrasound-guided injection using the in-plane, medial-to-lateral approach can accurately target the lumen of Achilles paratenon.
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