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Ultrasound guided dextrose injection for achilles tendonitis & plantar fasciitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Oct 30, 2007.

  1. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1

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    Press Release:
    Chronic Achilles Tendon Pain Eased By Ultrasound-Guided Injections
     
  2. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Re: Ultrasound guided dextrose injection for achilles tendonitis

    Sonographically Guided Intratendinous Injection of Hyperosmolar Dextrose to Treat Chronic Tendinosis of the Achilles Tendon: A Pilot Study
    Norman J. Maxwell, Michael B. Ryan, Jack E. Taunton, Jean H. Gillies and Anthony D. Wong
    AJR 2007; 189:W215-W220
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Sonographically Guided Intratendinous Injections of Hyperosmolar Dextrose/Lidocaine: A Pilot Study for the Treatment of Chronic Plantar Fasciitis.
    Ryan MB, Wong A, Gillies J, Wong J, Taunton J.
    Br J Sports Med. 2008 Nov 19. [Epub ahead of print]
     
  5. Steve The Footman

    Steve The Footman Active Member

    Is this any different to prolotherapy?

    How important is it to have the injections guided by ulrasound?
     
  6. joseph Paterson

    joseph Paterson Active Member

    This is an interesting paper, although Ultra Sound was used I wonder how many podiatrist wouyearsld have this facility in there own clinical setting?

    I do agree that the use of Prolotherapy is the next step forward in treating lower limb conditions that podiatrists have struggled with over the years in treatments for sports injuries to tendons, the question has to be can we afford expensive ultra sound equipment in our surgeries for the occasional use?
     
  7. Kent

    Kent Active Member

    Steve and Joseph,

    This is prolotherapy - just with ultrasound guidance. Prolotherapy is the injection of an irritant solution. Many solutions have been used in the past however lignocaine and glucose is most commonly used now. As it's only lignocaine and glucose being injected, it is not essential the ultrasound guidance is used. In fact, that's one of the real advantages of prolotherapy - it can be carried out in a general practice setting without the use of expensive equipment. If you were injecting Polidocinol, than I would say that ultrasound guidance is necessary.

    I suppose the only way of knowing whether ultrasound guidance is beneficial would would be to do an RCT - one group has prolotherapy with ultrasound guidance, the other gets prolotherapy without guidance.

    Personally I use prolotherapy virtually daily, especially on Achilles tendinosis and plantar fasciitis (generally if they've failed other treatments). I don't use ultrasound guidance and I get reasonable results. I get better results with Achilles tendons than plantar fasciitis patients and talking to other people, this is what they find, irrespective of what they use (e.g. prolotherapy, autologous blood, sclerosing agents etc) and how they inject it (guided vs unguided). So is it necessary to use ultrasound guidance if you're just injecting glucose and lignocaine - no. Would it help - maybe.

    Cheers,
    Kent
     
  8. joseph Paterson

    joseph Paterson Active Member

    Kent thanks for the helpful repy.
    I am currently looking at Prolotherapy as an addition to my skills, two points have come to mind 1) Technniqe and anatomy. 2) Can I obtain Glucose with just my LA or do I need to qualify for POMs?
    The second point is the most concerning.
    Joseph
     
  9. Kent

    Kent Active Member

    Joseph,

    A detailed understanding of the anatomy is essential. This was covered in the training course that I did, as is technique of course. When I checked with my registration board about performing prolotherapy, I was told as long as you can prove that you've had sufficient training, it's fine.

    Not sure what POMs is??? I was able to obtain 500ml 50% glucose bags through a medical supplier in Brisbane.

    Cheers,
    Kent
     
  10. Mart

    Mart Well-Known Member

    image 3 anotated.jpg

    image 1 anotated.jpg

    image 2 anotated.jpg

    I have recently started using dextrose infiltrations as second line of treatment for chronic plantar fasciosis which is not responding adequately to moderation of tensile stress with foot orthoses.
    I use Diagnostic ultrasound exam frequently with plantar heel pain to attempt better differential diagnosis. I rarely see inflammatory changes within aponeurosis with power doppler imaging but very commonly see evidence of degenerative changes. Based on hundreds of Diagnostic ultrasound exams for chronic plantar heel pain I believe that chronic plantar fasciitis is very rare.
    I am noticing a trend of those with measurable thickening exceeding 8mm to respond inadequately to rest, modification of footwear habits and foot orthoses. It is too early however to attempt any meaningful kind of statistical audit from my clinic notes.
    As far as using Diagnostic ultrasound exam to guide injection, I feel this is useful to be confident of location, I use it because it is fast and I can. The literature is mixed in terms of evidence that Diagnostic ultrasound guidance improves outcomes for a limited range of therapeutic injections.
    Where I think US may be useful is evaluating effects of therapy. To illustrate this I have attached some images from a couple of recent cases for discussion. My understanding is that prolotherapy may work by stimulating fibroblastic activity and laying down collagen within an otherwise largely mucoid degenerated structure. I increasingly believe that is likely that plantar heel pain may, in those with evidence of chronic plantar fasciosis be the result of overload of parallel musculature namely FDN, ADM and less likely AH rather than pain from within the aponeurosis. This is supported within the literature from studies of location and orientation of enthesites from cadavers.
    I believe the increased definition and reduced hypoechoicity seen in the images of the same patient , (using identical power, gain, and focal depths with same probe frequency and machine) before and after therapy may be result of collagen formation within aponeurosis. I cannot think what else might explain this, any suggestions? It coincided with VAS reduction of 7 to 4 and measureable reduction in margins of widest section of insertion of aponeurosis. I have also included a typical normal US image for those not accustomed to looking at these images.
    I am unaware of any non invasive method which may be used to investigate effect of prolotherapy other than US. If anyone else with access to high res US is interested in working up a methodology for long term clinical audit of US finding with dextrose infiltration for chronic plantar fasciosis please contact me, I think it would be a valuable project.
    Cheers
    Martin
    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  11. Mart

    Mart Well-Known Member

    Just to add to my last post.

    I saw a patient today who I think illustrates benefits of using Diagnostic ultrasound exam in decision making for plantar heel pain.

    It may interest those not using high res Diagnostic ultrasound and who are considering investing the time and money into this.

    I find this one of the most useful diagnostic tools I use for people with MSK injury of foot and ankle and would encourage everyone in our profession to take its potential seriously. I feel that since gaining some competence in interpretation, US has had a big impact in my diagnostic abilities for many of the injuries I exam.

    This patient had prior history of plantar heel pain (right foot) only dating from December 06.

    Diagnostic ultrasound exam identified both mild degenerative and inflammatory change in Feb 2007 right foot not left .

    Pain was not improved with use of foot orthoses after five months. At this point I supplied her with 3Mhz low power therapeutic US machine which she used at home TID for 10 minute sessions followed by tissue specific stretching.

    Pain resolved with 4 weeks of revised treatment. There were no significant changes seen with US in thickness but inflammation indicted with power doppler (PDI) was absent.

    In September 2008 she returned concerned regarding episodic left foot plantar heel pain, she had not used foot orthoses constantly since last visit but found pain resolved with use.

    Today she returned reporting left foot plantar heel pain worsening past six weeks in spite of constant foot orthoses use.

    IMAGES;

    image 1 anotated.jpg

    1 Left foot no pain Oct 07 - sag view - plantar fascia appears normal but large osteophyte deep to insertion of aponeurosis. Thickness measured within normal limits @ 4.5mm.

    image 2 anotated.jpg

    2 Left foot today, chronic pain – saggital view insertion thickened with slight hypoechoic areas visible

    image 3 anotated.jpg

    3 Similar view with power doppler (PDI) showing area of intense flow (arrowed) distal to enthesis.

    image 4 anotated.jpg


    4 Coronal view – slice at tip of enthesis similar evidence of intense flow.

    image 5 anotated.jpg

    5 Right foot symptomatic Oct 2007 – sag view showing fusiform thickening, slightly hypoechoic, and large osteophytes within and deep to body of aponeurosis. Slight flow was also detected at distal margins of enthesis (not shown here).


    6 Right foot asymptomatic currently, note reduction in thickness from 2007 although still above normal limits (2.4 to 4.8mm at widest slice) – no flow with PDI.

    This case is unusual and unique for me for 2 reasons; she is one of few pts I have examined with evidence of true fasciitis, (this coincides with only slight of signs of fasciosis seen as hypo-echoicity within fascia); she is the only person who I have examined at 14 months interval showing significant changes corresponding to symptoms on different feet.

    What I feel the Diagnostic ultrasound exam identified was;

    Initial right foot pain was possibly inflammatory rather than purely effects of degeneration. Right foot did not respond to foot orthoses (this fits the trend I am noticing of no resolution with foot orthoses when thickness exceeds 8mm).

    Immediate post pain resolution thickness measurement was not reduced but evidence of inflammation was. Thickness was however significantly reduced at 14 months and pain continued absent provided foot orthoses used. This was interesting because it is the first comparative measurement I have made at such long interval. When I started using US I used to do comparative exam at 4 to 8 weeks following treatment success (usually foot orthoses custom or prefab) and noticed no significant changes in plantar fascia. I stopped doing this follow up exam with US because the trend seemed unequivocal.

    This observation also started to make me think that the foot orthoses effect might not be related to effects on the fascia but possibly protection of parallel musculature. Prior discussions with Kevin Kirby on podarena around the notion of sub-periosteal inflammation associated with the fascia insertion (he believes this based on MRI evidence) remain a possibility though and this is beyond the limits of US to explore.

    Also there is evidence of correlation in these images of significant asymmetric symptom improvement and worsening and the morphologic changes seen with US which have been associated with plantar heel pain.

    In terms of treatment plan, it gives me instant and useful information to add to history, physical and gait exam.

    More ambitiosly, I feel US may provide good information regarding the possibility, over time, of meaningful clinical audit revealing if plantar heel pain, with multifaceted potential causes, may be more accurately sub categorized and treated accordingly.

    The lack of specificity which commonly plagues our diagnosis and treatment of plantar heel pain may also be confounding the value of existing studies because the study inclusion criteria could be too broad to be meaningful.

    Although some studies use US as a diagnostic inclusion criteria, non that I have seen use PDI to differentiate inflammation from degeneration and non sub divide subjects according to measurement.

    Any thoughts?

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
    Last edited: Dec 5, 2008
  12. Mart

    Mart Well-Known Member

    image #6 from last post (podarena limits uploads to max 5)
    ]


    image 6 anotated.jpg


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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