Achilles Tendinopathy Toolkit: Section F - Medical and Surgical Interventions: Difference between revisions

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* [[NSAIDs|Non-steroidal anti-inflammatory drugs (NSAIDs)]]  -  these have antipyretic, anti-inflammatory and analgesic properties.  In Achilles tendinopathy these are used in the acute stages to minimise the inflammatory process by interrupting the chemical pathway of inflammation.<ref>McLauchlan , G, Handoll, H. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Collaboration of Systemic Reviews. 2009;2:1‐36.</ref><ref>Karlsson, J., Brorsson, A., &amp; Silbernagel, K. (2014). Treatment of Chronic Achilles Tendinopathies. In G. Bentley (Ed.), European Instructional Lectures (Vol. 14, pp. 191-200): Springer Berlin Heidelberg.</ref>
* [[NSAIDs|Non-steroidal anti-inflammatory drugs (NSAIDs)]]  -  these have antipyretic, anti-inflammatory and analgesic properties.  In Achilles tendinopathy these are used in the acute stages to minimise the inflammatory process by interrupting the chemical pathway of inflammation.<ref>McLauchlan , G, Handoll, H. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Collaboration of Systemic Reviews. 2009;2:1‐36.</ref><ref>Karlsson, J., Brorsson, A., &amp; Silbernagel, K. (2014). Treatment of Chronic Achilles Tendinopathies. In G. Bentley (Ed.), European Instructional Lectures (Vol. 14, pp. 191-200): Springer Berlin Heidelberg.</ref>
* [[Therapeutic Corticosteroid Injection|Corticosteroid (injection)]] - often prescribed to help relieve pain and inflammation in a localised area of the body.  It involves an injection into the paratendon to interrupt the inflammatory process.<ref>DaCuz D, Geeson M, Allen M, Phair I. Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med. 1988;22(2):64‐65.</ref><ref>Shrier I, Matheson G, Kohl G. Achilles tendinitis: are corticosteroid injections useful or harmful? Clin J Sports Med. 1996;6(4):245‐250.</ref><ref>Fredberg U. Local corticosteroid injection in sport: a review of literature and guidelines for treatment. Scand J Med Sci Sports. 1997;7(3):131‐139.</ref><ref>Speed C. Corticosteroid injections in tendon lesions. Br Med J. 2001;323:382‐386.</ref>
[[File:Achilles Tendinopathy NSAIDS table.png|center|frameless|1049x1049px]]
* [[Tendinopathy Treatment Adjuncts#Glyceryl Trinitrate .28GTN.29|Glycerol Trinitrate (GTN)]] - the theory behind the use of GTN is that nitric oxide may increase blood flow to the tendon and stimulate repair by enhancing fibroblast proliferation.<ref>Paoloni J, Appleyard R, Nelson J, Murrell G. Topical GTN treatment of chronic non‐insertional Achilles tendinopathy. A randomized, double‐blind, placebo‐controlled trial. Journal of Bone and Joint Surgery ‐ America. 2004;86‐A(5):916‐922.</ref><ref>Hunter G, Lloyd‐Smith R. Topical GTN for chronic Achilles tendinopathy. Clin J Sports Med. 2005;15(2):116‐117.</ref><ref>Paolini J, Murrell G. Three year follow‐up study of topical GTN treatment of chronic non‐insertional Achilles tendinopathy. Foot and Ankle International. 2007;28(10):1064‐1068.</ref><ref>Gambit E, Gonzalez‐Suarez C, Oquinena T, Agbyani R. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systemic review and meta‐analysis. Arch Phys Med Rehabil. 2010;91(8):1291‐1305.</ref><ref>Kane, T. P., Ismail, M., &amp; Calder, J. D. (2008). Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. Am J Sports Med, 36(6), 1160-1163. doi: 10.1177/0363546508314423</ref>
*[[Therapeutic Corticosteroid Injection|Corticosteroid (injection)]] - often prescribed to help relieve pain and inflammation in a localised area of the body.  It involves an injection into the paratendon to interrupt the inflammatory process.<ref>DaCuz D, Geeson M, Allen M, Phair I. Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med. 1988;22(2):64‐65.</ref><ref>Shrier I, Matheson G, Kohl G. Achilles tendinitis: are corticosteroid injections useful or harmful? Clin J Sports Med. 1996;6(4):245‐250.</ref><ref>Fredberg U. Local corticosteroid injection in sport: a review of literature and guidelines for treatment. Scand J Med Sci Sports. 1997;7(3):131‐139.</ref><ref>Speed C. Corticosteroid injections in tendon lesions. Br Med J. 2001;323:382‐386.</ref>
 
[[File:Achilles Tendinopathy Corticosteroid table.png|center|frameless|1055x1055px]]
=== NSAIDS ===
*[[Tendinopathy Treatment Adjuncts#Glyceryl Trinitrate .28GTN.29|Glycerol Trinitrate (GTN)]] - the theory behind the use of GTN is that nitric oxide may increase blood flow to the tendon and stimulate repair by enhancing fibroblast proliferation.<ref>Paoloni J, Appleyard R, Nelson J, Murrell G. Topical GTN treatment of chronic non‐insertional Achilles tendinopathy. A randomized, double‐blind, placebo‐controlled trial. Journal of Bone and Joint Surgery ‐ America. 2004;86‐A(5):916‐922.</ref><ref>Hunter G, Lloyd‐Smith R. Topical GTN for chronic Achilles tendinopathy. Clin J Sports Med. 2005;15(2):116‐117.</ref><ref>Paolini J, Murrell G. Three year follow‐up study of topical GTN treatment of chronic non‐insertional Achilles tendinopathy. Foot and Ankle International. 2007;28(10):1064‐1068.</ref><ref>Gambit E, Gonzalez‐Suarez C, Oquinena T, Agbyani R. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systemic review and meta‐analysis. Arch Phys Med Rehabil. 2010;91(8):1291‐1305.</ref><ref>Kane, T. P., Ismail, M., &amp; Calder, J. D. (2008). Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. Am J Sports Med, 36(6), 1160-1163. doi: 10.1177/0363546508314423</ref>
 
[[File:Achilles Tendinopathy GTN table.png|center|frameless|1075x1075px]]
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
| colspan="2" |'''Method'''
| Short term benefit in the acute stage of tendinopathy to minimise inflammatory process.
|-
| colspan="2" |'''Proposed Mechanism'''
| Interrupts the chemical pathway of inflammation.
|-
| rowspan="2" |'''Benefit: Pros/Cons'''<br>
|'''Pros:'''
|
*Inexpensive, easily accessible.
 
|-
|'''Cons:'''
|
*Precautions and contraindications&nbsp;that accompany&nbsp;specific medications.
*Inhibition of inflammation may&nbsp;delay repair of muscle tissue or tendon insertion.
 
|-
| colspan="2" |'''Evidence'''
|
Limited evidence for a modest effect of topical or oral NSAIDs in acute stage in Achilles tendinopathy.
 
<br>
 
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''
 
| PTs are involved in the treatment of tendon pain at all stages of recovery. General knowledge of commonly used NSAIDS is important for treatment planning.
|}
 
=== Corticosteroid (injection) ===
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
| colspan="2" |'''Method'''
| Short‐term benefit in acute stage. In chronic tendinopathy, the rationale for the use of&nbsp;anti-inflammatory injections is controversial.
|-
| colspan="2" |'''Proposed Mechanism'''
| Injection into the paratendon to interrupt the inflammatory process.
|-
| rowspan="2" |'''Benefit: Pros/Cons'''<br>
|'''Pros:'''
|
*Easily accessible.
*Careful administration outside the structure of the tendon is considered ‘safe’ i.e., in the paratendon sheath.
 
|-
|'''Cons:'''
|
*Risk of infection (1%) ‘universal precautions’ required.
*Destructive; risk of tendon rupture; impairs tendon tissue repair mechanism.
 
|-
| colspan="2" |'''Evidence'''
| There is a lack of high quality evidence to support the use of local corticosteroid injections in chronic Achilles tendon lesions. Generally, lack of well‐designed clinical trials.
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''
 
| PTs are involved in the treatment of tendon pain at all stages of recovery. There are animal studies that suggest risk of tendon rupture after corticosteroid injection. Caution is recommended in progressing the loading of the tendon within two weeks of a corticosteroid injection (exercise precautions).
|}
 
=== Glycerol Trinitrate (GTN) ===
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
| colspan="2" |'''Method'''
| Nitro‐glycerine patches applied over tendon to enhance healing.
|-
| colspan="2" |'''Proposed Mechanism'''
| Nitric oxide may increase blood flow to the tendon and stimulate repair by enhancing fibroblast proliferation.
|-
| rowspan="2" |'''Benefit: Pros/Cons'''<br>
|'''Pros:'''
|
*GTN may improve outcomes compared to exercise alone.
*Increased compliance because of ease of application. Selfapplied.
*Non‐invasive.
 
|-
|'''Cons:'''
|
*Labour‐ intensive; requires repeated applications over 12 weeks.
*Potential headache as a side-effect of nitro patch.
 
|-
| colspan="2" |'''Evidence'''
| Conflicting evidence limits conclusions and widespread use.<br>
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''
 
| If prescribed by a physician, may be applied by a physiotherapist and used in conjunction with an eccentric exercise program.
|}


== Injection Therapies  ==
== Injection Therapies  ==
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Chronic Achilles tendinopathy is associated with abnormal proliferation of neovessels in the ventral portion of the tendon, and along with accompanying neural tissue, is associated with pain in tendinopathy. The presence of neovessels can be visualized by use of ultrasound (US) (sonography). Grey‐scale US is a reliable method to assess tendon structure. Color Doppler or power Doppler has also been used to visualize blood flow.  
Chronic Achilles tendinopathy is associated with abnormal proliferation of neovessels in the ventral portion of the tendon, and along with accompanying neural tissue, is associated with pain in tendinopathy. The presence of neovessels can be visualized by use of ultrasound (US) (sonography). Grey‐scale US is a reliable method to assess tendon structure. Color Doppler or power Doppler has also been used to visualize blood flow.  


Conservative treatment for Achilles tendinopathy is unsuccessful in 24‐45% of cases. US‐guided injections are becoming increasingly considered as part of ‘best practice’ for treatment of tendinopathies that have failed to respond to other conservative treatment.  
Conservative treatment for Achilles tendinopathy is unsuccessful in 24‐45% of cases. US‐guided injections are becoming increasingly considered as part of ‘best practice’ for treatment of tendinopathies that have failed to respond to other conservative treatment.  Injection therapy options include:  
 
=== Polidocanol<ref>Ohberg L, Alfredson H. US‐guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of new treatment (original article). Br Med Association. 2001;p 1‐7.</ref><ref>Alfredson H, Ohberg L. Sclerosing injections to areas of neovascularization reduces pain in chronic Achilles tendinopathy: a double‐blinded randomized trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2005;13:338‐344.</ref><ref>Alfredson H, Ohberg L, Zeisig E, Lorentzan R. Treatment of mid‐portion Achilles tendinosis: similar clinical results with US and CD‐guided surgery outside the tendon and sclerosing polidocanol injections. Knee Surgery, Sports Traumatology, Arthroscopy. 2007;15:1504‐1509.</ref><ref>Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlstrom M, Alfredson H. Sclerosing injections to treat mid‐portion Achilles tendinosis: a randomized controlled study evaluating two different concentrations of polidocanol. Knee Surgery, Sports Traumatology, Arthroscopy. 2008;16:859‐864.</ref><ref>Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.</ref><ref>van Sterkenburg M, Jonge M. Less promising results with sclerosing ethoxysclerol (polidocanol) injections for mid‐portion Achilles tendinopathy. Am J Sports Med. 2010;38(11):2226‐2232.</ref> ===
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
| colspan="2" | '''Method'''
| Originally developed as an anaesthetic, and widely used as a sclerosing agent in the treatment of varicose veins.
|-
| colspan="2" | '''Proposed Mechanism'''
| There is a body of literature that supports the use of US-guided injections of polidocanol to disrupt neovessels and accompanying nerve structures associated with chronic tendinopathy.
|-
| rowspan="2" | '''Benefit: Pros/Cons'''<br>
| '''Pros:'''
|
*Increasingly used, registered drug with few side‐effects.
*No need to use additional anaesthetic, as it has its own aesthetic properties.
 
|-
| '''Cons:'''
|
*Expensive sonography equipment, requiring an experienced operator.
 
|-
| colspan="2" | '''Evidence'''
| Conflicting evidence limits conclusions and widespread use.<br>
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''
 
| PTs should have knowledge of more invasive techniques to help to facilitate referral of patients to other procedures when conventional treatment fails to result in a sufficient positive response.
|}
 
=== Prolotherapy<ref>Ryan M, Wong A, Taunton J. Favorable outcomes after US‐guided intertendinous injection of hyerosmolar dextrose for chronic insertional and mid‐portion Achilles tendinitis. (Original research). Am J Roengentoloty. 2010;194:1047‐1053.</ref><ref name="Wijesekera 2010">Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.</ref><ref>Yelland, M. J., Sweeting, K. R., Lyftogt, J. A., Ng, S. K., Scuffham, P. A., &amp; Evans, K. A. (2011). Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med, 45(5), 421-428. doi: 10.1136/bjsm.2009.057968</ref>  ===
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
| colspan="2" | '''Method'''
| Injecting a small volume of an irritant solution at multiple sites around a tendon insertion to induce a ‘pro-inflammatory’ proliferative cell response. One study used hyperosmolar dextrose while another used hypertonic glucose, both with a small amount of anaesthetic.
|-
| colspan="2" | '''Proposed Mechanism'''
|
Fibroblast proliferation, collagen maturation and resolution of neovessels are observed, with near normal appearance of tendon tissue structure observed with US.
 
New viable tissue hypothesised to result from local release of cell growth factors.
 
Medical dextrose also has a weak sclerosing effect on vessels.
 
|-
| rowspan="2" | '''Benefit: Pros/Cons'''<br>
| '''Pros:'''
|
*Can be performed with or without US‐guided localisation.&nbsp;
 
|-
| '''Cons:'''
|
*Not covered by medical plans (BC); usually requires a private fee that reflects the expertise of the practitioner.
*Requires three or more repeated treatments.<br>


|-
* [[Achilles Tendinopathy#Medical Management|Polidocanol]] - This is a vascular sclerosant that was originally developed as an anaesthetic and is often used in the treatment of varicose veins.  It is used to disrupt neovessels and accompanying nerve structures associated with chronic tendinopathy. <ref>Ohberg L, Alfredson H. US‐guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of new treatment (original article). Br Med Association. 2001;p 1‐7.</ref><ref>Alfredson H, Ohberg L. Sclerosing injections to areas of neovascularization reduces pain in chronic Achilles tendinopathy: a double‐blinded randomized trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2005;13:338‐344.</ref><ref>Alfredson H, Ohberg L, Zeisig E, Lorentzan R. Treatment of mid‐portion Achilles tendinosis: similar clinical results with US and CD‐guided surgery outside the tendon and sclerosing polidocanol injections. Knee Surgery, Sports Traumatology, Arthroscopy. 2007;15:1504‐1509.</ref><ref>Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlstrom M, Alfredson H. Sclerosing injections to treat mid‐portion Achilles tendinosis: a randomized controlled study evaluating two different concentrations of polidocanol. Knee Surgery, Sports Traumatology, Arthroscopy. 2008;16:859‐864.</ref><ref>Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.</ref><ref>van Sterkenburg M, Jonge M. Less promising results with sclerosing ethoxysclerol (polidocanol) injections for mid‐portion Achilles tendinopathy. Am J Sports Med. 2010;38(11):2226‐2232.</ref>
| colspan="2" | '''Evidence'''
| Limited evidence suggests that prolotherapy combined with eccentric exercise for Achilles tendon loading may provide more rapid improvement in symptoms than eccentrics alone, although long‐term VISA‐A scores are similar.
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''


| Prolotherapy may enhance outcomes compared to using eccentric exercise, alone.
[Insert Table from Toolkit]
|}


=== Platelet Rich Plasma (PRP) and Autologous whole blood<ref name="Wijesekera 2010" /><ref>De Vos R, Weir A, et al. PRP injection for chronic Achilles tendinopathy. Journal of the American Medical Association. 2010;303(3):144‐149.</ref><ref>Engebretsen L, Steffen K, et al. IOC consensus paper on use of PRP in sports medicine. British Journal of Sports Medicine. 2010;44(15):1072‐1081.</ref><ref>De Jonge S, de Vos R, Weir A, et al. 1‐year follow‐up of PRP treatment in chronic Achilles tendinopathy: a double‐blind random placebo‐controlled trial. American Journal of Sports Medicine. 2011;39(8):1623‐1629.</ref><ref>Bell, K. J., Fulcher, M. L., Rowlands, D. S., &amp; Kerse, N. (2013). Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial (Vol. 346).</ref> ===
* Prolotherapy - This involves injecting an irritant solution, such as hypersomolar dextrose, into multiple sites around the tendon insertion.  This stimulates a pro-inflammatory proliferative cell response to increase tissue healing and reduce pain.<ref>Ryan M, Wong A, Taunton J. Favorable outcomes after US‐guided intertendinous injection of hyerosmolar dextrose for chronic insertional and mid‐portion Achilles tendinitis. (Original research). Am J Roengentoloty. 2010;194:1047‐1053.</ref><ref name="Wijesekera 2010">Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.</ref><ref>Yelland, M. J., Sweeting, K. R., Lyftogt, J. A., Ng, S. K., Scuffham, P. A., &amp; Evans, K. A. (2011). Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med, 45(5), 421-428. doi: 10.1136/bjsm.2009.057968</ref>


{| width="700" border="1" cellpadding="1" cellspacing="1"
[Insert Table from Toolkit]
|-
| colspan="2" | '''Method'''
| Autologous blood injections involve the reinjection of a patient’s own whole blood. <br>In PRP the autologous blood is centrifuged to collect a concentrate of the platelets and plasma. This is then injected back into the patient’s tendon.<br>
|-
| colspan="2" | '''Proposed Mechanism'''
| Cellular and humoral (blood) mediators promote healing in areas of tendon degeneration.
|-
| rowspan="2" | '''Benefit: Pros/Cons'''<br>
| '''Pros:'''
|
*Non-surgical option
*Can be performed with or without US-guided localization<br>


|-
* [[Platelet-Rich Plasma (PRP) Therapy|Platelet Rich Plasma (PRP)]] and Autologous Whole Blood - This is known as regenerative medicine and involves reinjection, into the tendon, of the patient's own whole blood (autologous) or centrifugation of the blood to collect a concentrate of the platelets and plasma.  The procedure promotes healing in areas of tendon degeneratiion.<ref name="Wijesekera 2010" /><ref>De Vos R, Weir A, et al. PRP injection for chronic Achilles tendinopathy. Journal of the American Medical Association. 2010;303(3):144‐149.</ref><ref>Engebretsen L, Steffen K, et al. IOC consensus paper on use of PRP in sports medicine. British Journal of Sports Medicine. 2010;44(15):1072‐1081.</ref><ref>De Jonge S, de Vos R, Weir A, et al. 1‐year follow‐up of PRP treatment in chronic Achilles tendinopathy: a double‐blind random placebo‐controlled trial. American Journal of Sports Medicine. 2011;39(8):1623‐1629.</ref><ref>Bell, K. J., Fulcher, M. L., Rowlands, D. S., &amp; Kerse, N. (2013). Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial (Vol. 346).</ref>
| '''Cons:'''
|
*RCT-level evidence of lack of effectiveness
*Requires expensive blood processing equipment and centrifuge. Also, it is a US-guided technique requiring sonography and an experienced operator.


|-
[Insert Table from Toolkit]
| colspan="2" | '''Evidence'''
| Two high-quality RCTs have shown both PRP and autologous whole blood injection to be ineffective.
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''


| PTs are part of a treatment team when treating tendon injury. General knowledge of PRP and relevant high quality RCTs is important to assist patients in decision-making.
* High Volume Injection (HVI) or Hydrostatic Dissection - In this procedure a small volume of anaesthetic/steroid and high volume saline is delivered by ultrasound guided imaging.  The pressure created by the volume of substance into the tendon sheath thought to disrupt the neovessel ingrowth, resetting the healing process and reducing pain.<ref>Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disability and Rehabilitation. 2008;30:1697‐1708.</ref><ref>Maffulli, N., Spiezia, F., Longo, U. G., Denaro, V., &amp; Maffulli, G. D. (2013). High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Physical Therapy in Sport, 14(3), 163-167. doi: http://dx.doi.org/10.1016/j.ptsp.2012.07.002</ref><ref>Boesen, A., Boesen, M., Hansen, R., Malliaras, P., Chan, O., &amp; Langberg, H. (2014). 61 High Volume Injection, Platelet Rich Plasma And Placebo In Chronic Achilles Tendinopathy–A Double Blind Prospective Study. British Journal of Sports Medicine, 48(Suppl 2), A39-A40.</ref>
|}


=== High volume injection (HVI) or Hydrostatic dissection<ref>Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disability and Rehabilitation. 2008;30:1697‐1708.</ref><ref>Maffulli, N., Spiezia, F., Longo, U. G., Denaro, V., &amp; Maffulli, G. D. (2013). High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Physical Therapy in Sport, 14(3), 163-167. doi: http://dx.doi.org/10.1016/j.ptsp.2012.07.002</ref><ref>Boesen, A., Boesen, M., Hansen, R., Malliaras, P., Chan, O., &amp; Langberg, H. (2014). 61 High Volume Injection, Platelet Rich Plasma And Placebo In Chronic Achilles Tendinopathy–A Double Blind Prospective Study. British Journal of Sports Medicine, 48(Suppl 2), A39-A40.</ref>  ===
[Insert Table from Toolkit]


{| width="700" border="1" cellpadding="1" cellspacing="1"
== Dry Needling ==
|-
[[Dry needling|Dry Needling]] involves using a fine hypodermic needle or acupuncture needle that does not involve the injection of a substance.  The technique is sometimes referred to as "tendon fenestration"<ref>Housner J, Jacobsen J, Misko R. Sonographically guided percutaneous needle tenotomy for treatment of chronic tendinosis. Journal of Ultrasound Medicine. 2009;28(8):1187‐1192.</ref> The needle is inserted into the tendon a number of times which creates an haemorrhagic response.  This is followed by an inflammatory response, granulation and healing.
| colspan="2" | '''Method'''
| Small volume of anaesthetic/steroid and high volume of saline, delivered by US‐guided imaging.
|-
| colspan="2" | '''Proposed Mechanism'''
| The pressure created by the volume of substance into the tendon sheath is proposed to disrupt the neovessel ingrowth in Achilles tendinopathy.
|-
| rowspan="2" | '''Benefit: Pros/Cons'''<br>
| '''Pros:'''
|
*Non‐surgical option.


|-
[Insert table]Surgical Approaches
| '''Cons:'''
|
*Requires sonography equipment.
 
|-
| colspan="2" | '''Evidence'''
| Limited evidence of effectiveness.
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''
 
| Potential treatment option for Achilles tendinopathy that has failed to respond to a more conservative approach.
|}
 
== Dry Needling  ==
 
The term ‘dry needling’ has been used to describe several techniques that involve insertion of a needle without injection of a substance. Needling of the tendon has been described by a number of practitioners using a hypodermic needle. Similar results using acupuncture needles have become more common. The technique is described below.
 
=== Dry Needline using a Hypordermic Needle ("tendon fenestration")<ref>Housner J, Jacobsen J, Misko R. Sonographically guided percutaneous needle tenotomy for treatment of chronic tendinosis. Journal of Ultrasound Medicine. 2009;28(8):1187‐1192.</ref>  ===
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
| colspan="2" | '''Method'''
| Tissue trauma from the cutting edge of the needle/lumen.
|-
| colspan="2" | '''Proposed Mechanism'''
| Repeated lancing of abnormal tendon tissue creates haemorrhage followed by an inflammatory response, granulation and healing. Some needling techniques employ US to guide the needle (percutaneous needle tenotomy).
|-
| rowspan="2" | '''Benefit: Pros/Cons'''<br>
| '''Pros:'''
|
*Invasive treatment that avoids full surgical exposure and risks.
 
|-
| '''Cons:'''
|
*Requires sonography equipment.
*Potential to permanently injure the tendon
 
|-
| colspan="2" | '''Evidence'''
| Limited evience of effectiveness.
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''
 
| An invasive treatment with limited evidence.
|}
 
== Surgical Approaches ==


Surgical success rates are reported at 85% for Achilles tendinopathy that have failed to respond to conservative measures.  
Surgical success rates are reported at 85% for Achilles tendinopathy that have failed to respond to conservative measures.  


=== Percutaneous tenetomy<ref>Testa V, Capasso G, Benazzo F, Muffulli N. Management of Achilles tendinopathy by US‐guided percutaneous tenotomy. Medicine and Science in Sports and Exercise. 2002;34(4):573‐580.</ref><ref>Maffulli, N., Oliva, F., Testa, V., Capasso, G., &amp; Del Buono, A. (2013). Multiple Percutaneous Longitudinal Tenotomies for Chronic Achilles Tendinopathy in Runners A Long-Term Study. The American journal of sports medicine, 41(9), 2151-2157.</ref>  ===
== Surgical Approaches ==
Surgical success rates are reported at 8% for Achilles tendinopathy that have failed to respond to conservative measures.


{| width="700" border="1" cellpadding="1" cellspacing="1"
* Percutaneous tenotomy - This technique involves a  closed dissection of the tendon sheath by ultrasound guided percutaneous longitudinal internal tenotomy or an open surgical exposure of the tendon. <ref>Testa V, Capasso G, Benazzo F, Muffulli N. Management of Achilles tendinopathy by US‐guided percutaneous tenotomy. Medicine and Science in Sports and Exercise. 2002;34(4):573‐580.</ref><ref>Maffulli, N., Oliva, F., Testa, V., Capasso, G., &amp; Del Buono, A. (2013). Multiple Percutaneous Longitudinal Tenotomies for Chronic Achilles Tendinopathy in Runners A Long-Term Study. The American journal of sports medicine, 41(9), 2151-2157.</ref>
|-
| colspan="2" | '''Method'''
| Techniques include closed dissection of the tendon sheath by US‐guided percutaneous longitudinal internal tenotomy; or open&nbsp;surgical exposure of the tendon.
|-
| colspan="2" | '''Proposed Mechanism'''
| Surgical trauma creates granulation and repair, and interrupts fibrous adhesions.
|-
| rowspan="2" | '''Benefit: Pros/Cons'''<br>  
| '''Pros:'''
|
*Simple procedure that can be done as an outpatient.<br>


|-
[Insert Table from Toolkit]
| '''Cons:'''
|
*Risk of infection.


|-
* Surgical debridement - A central longitudinal incision is made to expose the tendon.  The disorganised and fibrotic tendon tissue and adhesions is then excised with the application diathermy to destroy neovessels. The surgery creates granulation and repair, and removes the fibrotic tissue.<ref>Tallon C, Coleman B, Khan K, Maffulli N. Outcomes of surgery of chronic Achilles tendinopathy. Am J Sports Med. 2001;29(3):315‐320.</ref><ref>Maffulli, N., Del Buono, A., Testa, V., Capasso, G., Oliva, F., &amp; Denaro, V. (2011). Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision. Journal of Bone &amp; Joint Surgery, British Volume, 93(11), 1503-1507.</ref>
| colspan="2" | '''Evidence'''
| Satisfactory outcomes for selected patients that do not have complicated Achilles pathology, and have failed to respond to a conservative treatment approach.&nbsp;Treatment seems to be effective in the long-term with regard to returning to pre-injury level of functioning. Paratendinopathy is a negative prognostic factor.
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''


| PT may be involved in the post‐op rehabilitation following surgery.
[Insert Table from Toolkit]
|}


=== Surgical debridement<ref>Tallon C, Coleman B, Khan K, Maffulli N. Outcomes of surgery of chronic Achilles tendinopathy. Am J Sports Med. 2001;29(3):315‐320.</ref><ref>Maffulli, N., Del Buono, A., Testa, V., Capasso, G., Oliva, F., &amp; Denaro, V. (2011). Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision. Journal of Bone &amp; Joint Surgery, British Volume, 93(11), 1503-1507.</ref> ===
* Minimally invasive stripping - A small incision is made allowing a probe or scalpel to be inserted ventral to the tendon. The area of neovascularisation is stripped.  This disrupts the abnormal blood/nerve supply, releases adhesions. <ref>Longo UG, Ramamurthy C, Denaro V, Maffulli N. Minimally invasive stripping for chronic Achilles tendinopathy. Disabil Rehabil. 2008;30(20‐22):1709‐13.</ref>
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
| colspan="2" | '''Method'''
| Central longitudinal incision to expose the tendon, with<br>excision of disorganised and fibrotic tendon tissue and adhesions. Additional diathermy to destroy neovessels.
|-
| colspan="2" | '''Proposed Mechanism'''
| Surgery creates granulation and repair, and removes fibrotic tissue.
|-
| rowspan="2" | '''Benefit: Pros/Cons'''<br>
| '''Pros:'''
|
*High success rates reported by some centres in terms of reducing pain and improving functionality
 
|-
| '''Cons:'''
|
*Risk of infection.
*Long post‐op recovery of 3‐6 months.
 
|-
| colspan="2" | '''Evidence'''
| Surgery may be a successful option for patients that have failed to respond to conservative treatment, or have complicated Achilles tendon pathology.
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''
 
| PT may be involved in the post‐op rehabilitation following surgery.
|}
 
=== Minimally invasive stripping<ref>Longo UG, Ramamurthy C, Denaro V, Maffulli N. Minimally invasive stripping for chronic Achilles tendinopathy. Disabil Rehabil. 2008;30(20‐22):1709‐13.</ref> ===
 
{| width="700" border="1" cellpadding="1" cellspacing="1"
|-
| colspan="2" | '''Method'''
| Small incision in made allowing a probe or scapel to be inserted ventral to the tendon. The area of neovascularisation is stripped.
|-
| colspan="2" | '''Proposed Mechanism'''
| Disrupts abnormal blood/nerve supply, releases adhesions.
|-
| rowspan="2" | '''Benefit: Pros/Cons'''<br>
| '''Pros:'''
|
*High success rate reported.
*Minimal trauma to tendon
*Quick return to sport
*Reduced risk of infection comparing to open surgery
 
|-
| '''Cons:'''
|
*Risk of infection.
*Potential loss of gliding function due to long term increased
 
|-
| colspan="2" | '''Evidence'''
| Retrospective, short-term studies only
|-
| colspan="2" |
'''Take Home Message '''''<br>'<nowiki/>'''''Implications for Physiotherapy'''
 
| PT may be involved in the post‐op rehabilitation following surgery.
|}


== Resources ==
* Click to go back to the [[Achilles Tendinopathy Toolkit|Main Achilles Tendinopathy Toolkit page]]
* Click to go back to the [[Achilles Tendinopathy Toolkit|Main Achilles Tendinopathy Toolkit page]]
* Click to go back to [[Achilles Tendinopathy Toolkit: Section A - Clinical Evaluation|Section A - Clinical Evaluation]]
* Click to go back to [[Achilles Tendinopathy Toolkit: Section A - Clinical Evaluation|Section A - Clinical Evaluation]]
Line 389: Line 65:
* Click to go back to [[Achilles Tendinopathy Toolkit: Section D - Exercise Programs|Section D - Exercise Programs]]
* Click to go back to [[Achilles Tendinopathy Toolkit: Section D - Exercise Programs|Section D - Exercise Programs]]
* Click to go back to [[Achilles Tendinopathy Toolkit: Section E - Low Level Laser Therapy Dosage Calculation|Section E - Low Level Laser Therapy Dosage Calculation]]
* Click to go back to [[Achilles Tendinopathy Toolkit: Section E - Low Level Laser Therapy Dosage Calculation|Section E - Low Level Laser Therapy Dosage Calculation]]
 
* [https://med-fom-clone-pt.sites.olt.ubc.ca/files/2021/10/ATT-Final-Version-Oct-19th-21.pdf#page=16&zoom=100,0,0 UBC Achilles Tendinopathy Toolkit]
== Download&nbsp;Achilles Tendinopathy Toolkit: Appendix D  ==
 
[[Image:Download Appendix D - Medical and Surgical Interventions.pdf]]  
 
= References  =
= References  =


Revision as of 15:36, 22 July 2022

This article is currently under review and may not be up to date. Please come back soon to see the finished work! (22/07/2022)

Introduction[edit | edit source]

The purpose of this document is to summarize common medical and surgical interventions which may be considered for the management of Achilles tendinopathy – particularly if it is not responding adequately to recommended conservative management strategies (see “Achilles Tendinopathy: Summary of the Evidence for Physical Therapy Interventions”).

Pharmacological Approaches[edit | edit source]

There is limited evidence, and in some cases no evidence, to support the use of pharmacological interventions in the treatment of achilles tendinopathy. The 3 most commonly used pharmacological approaches are:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) - these have antipyretic, anti-inflammatory and analgesic properties. In Achilles tendinopathy these are used in the acute stages to minimise the inflammatory process by interrupting the chemical pathway of inflammation.[1][2]
Achilles Tendinopathy NSAIDS table.png
  • Corticosteroid (injection) - often prescribed to help relieve pain and inflammation in a localised area of the body. It involves an injection into the paratendon to interrupt the inflammatory process.[3][4][5][6]
Achilles Tendinopathy Corticosteroid table.png
Achilles Tendinopathy GTN table.png

Injection Therapies[edit | edit source]

Chronic Achilles tendinopathy is associated with abnormal proliferation of neovessels in the ventral portion of the tendon, and along with accompanying neural tissue, is associated with pain in tendinopathy. The presence of neovessels can be visualized by use of ultrasound (US) (sonography). Grey‐scale US is a reliable method to assess tendon structure. Color Doppler or power Doppler has also been used to visualize blood flow.

Conservative treatment for Achilles tendinopathy is unsuccessful in 24‐45% of cases. US‐guided injections are becoming increasingly considered as part of ‘best practice’ for treatment of tendinopathies that have failed to respond to other conservative treatment. Injection therapy options include:

  • Polidocanol - This is a vascular sclerosant that was originally developed as an anaesthetic and is often used in the treatment of varicose veins. It is used to disrupt neovessels and accompanying nerve structures associated with chronic tendinopathy. [12][13][14][15][16][17]

[Insert Table from Toolkit]

  • Prolotherapy - This involves injecting an irritant solution, such as hypersomolar dextrose, into multiple sites around the tendon insertion. This stimulates a pro-inflammatory proliferative cell response to increase tissue healing and reduce pain.[18][19][20]

[Insert Table from Toolkit]

  • Platelet Rich Plasma (PRP) and Autologous Whole Blood - This is known as regenerative medicine and involves reinjection, into the tendon, of the patient's own whole blood (autologous) or centrifugation of the blood to collect a concentrate of the platelets and plasma. The procedure promotes healing in areas of tendon degeneratiion.[19][21][22][23][24]

[Insert Table from Toolkit]

  • High Volume Injection (HVI) or Hydrostatic Dissection - In this procedure a small volume of anaesthetic/steroid and high volume saline is delivered by ultrasound guided imaging. The pressure created by the volume of substance into the tendon sheath thought to disrupt the neovessel ingrowth, resetting the healing process and reducing pain.[25][26][27]

[Insert Table from Toolkit]

Dry Needling[edit | edit source]

Dry Needling involves using a fine hypodermic needle or acupuncture needle that does not involve the injection of a substance. The technique is sometimes referred to as "tendon fenestration"[28] The needle is inserted into the tendon a number of times which creates an haemorrhagic response. This is followed by an inflammatory response, granulation and healing.

[Insert table]Surgical Approaches

Surgical success rates are reported at 85% for Achilles tendinopathy that have failed to respond to conservative measures.

Surgical Approaches[edit | edit source]

Surgical success rates are reported at 8% for Achilles tendinopathy that have failed to respond to conservative measures.

  • Percutaneous tenotomy - This technique involves a closed dissection of the tendon sheath by ultrasound guided percutaneous longitudinal internal tenotomy or an open surgical exposure of the tendon. [29][30]

[Insert Table from Toolkit]

  • Surgical debridement - A central longitudinal incision is made to expose the tendon. The disorganised and fibrotic tendon tissue and adhesions is then excised with the application diathermy to destroy neovessels. The surgery creates granulation and repair, and removes the fibrotic tissue.[31][32]

[Insert Table from Toolkit]

  • Minimally invasive stripping - A small incision is made allowing a probe or scalpel to be inserted ventral to the tendon. The area of neovascularisation is stripped. This disrupts the abnormal blood/nerve supply, releases adhesions. [33]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ McLauchlan , G, Handoll, H. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Collaboration of Systemic Reviews. 2009;2:1‐36.
  2. ↑ Karlsson, J., Brorsson, A., & Silbernagel, K. (2014). Treatment of Chronic Achilles Tendinopathies. In G. Bentley (Ed.), European Instructional Lectures (Vol. 14, pp. 191-200): Springer Berlin Heidelberg.
  3. ↑ DaCuz D, Geeson M, Allen M, Phair I. Achilles paratendonitis: an evaluation of steroid injection. Br J Sports Med. 1988;22(2):64‐65.
  4. ↑ Shrier I, Matheson G, Kohl G. Achilles tendinitis: are corticosteroid injections useful or harmful? Clin J Sports Med. 1996;6(4):245‐250.
  5. ↑ Fredberg U. Local corticosteroid injection in sport: a review of literature and guidelines for treatment. Scand J Med Sci Sports. 1997;7(3):131‐139.
  6. ↑ Speed C. Corticosteroid injections in tendon lesions. Br Med J. 2001;323:382‐386.
  7. ↑ Paoloni J, Appleyard R, Nelson J, Murrell G. Topical GTN treatment of chronic non‐insertional Achilles tendinopathy. A randomized, double‐blind, placebo‐controlled trial. Journal of Bone and Joint Surgery ‐ America. 2004;86‐A(5):916‐922.
  8. ↑ Hunter G, Lloyd‐Smith R. Topical GTN for chronic Achilles tendinopathy. Clin J Sports Med. 2005;15(2):116‐117.
  9. ↑ Paolini J, Murrell G. Three year follow‐up study of topical GTN treatment of chronic non‐insertional Achilles tendinopathy. Foot and Ankle International. 2007;28(10):1064‐1068.
  10. ↑ Gambit E, Gonzalez‐Suarez C, Oquinena T, Agbyani R. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systemic review and meta‐analysis. Arch Phys Med Rehabil. 2010;91(8):1291‐1305.
  11. ↑ Kane, T. P., Ismail, M., & Calder, J. D. (2008). Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation. Am J Sports Med, 36(6), 1160-1163. doi: 10.1177/0363546508314423
  12. ↑ Ohberg L, Alfredson H. US‐guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of new treatment (original article). Br Med Association. 2001;p 1‐7.
  13. ↑ Alfredson H, Ohberg L. Sclerosing injections to areas of neovascularization reduces pain in chronic Achilles tendinopathy: a double‐blinded randomized trial. Knee Surgery, Sports Traumatology, Arthroscopy. 2005;13:338‐344.
  14. ↑ Alfredson H, Ohberg L, Zeisig E, Lorentzan R. Treatment of mid‐portion Achilles tendinosis: similar clinical results with US and CD‐guided surgery outside the tendon and sclerosing polidocanol injections. Knee Surgery, Sports Traumatology, Arthroscopy. 2007;15:1504‐1509.
  15. ↑ Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlstrom M, Alfredson H. Sclerosing injections to treat mid‐portion Achilles tendinosis: a randomized controlled study evaluating two different concentrations of polidocanol. Knee Surgery, Sports Traumatology, Arthroscopy. 2008;16:859‐864.
  16. ↑ Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.
  17. ↑ van Sterkenburg M, Jonge M. Less promising results with sclerosing ethoxysclerol (polidocanol) injections for mid‐portion Achilles tendinopathy. Am J Sports Med. 2010;38(11):2226‐2232.
  18. ↑ Ryan M, Wong A, Taunton J. Favorable outcomes after US‐guided intertendinous injection of hyerosmolar dextrose for chronic insertional and mid‐portion Achilles tendinitis. (Original research). Am J Roengentoloty. 2010;194:1047‐1053.
  19. ↑ 19.0 19.1 Wijesekera N, Chew N, Lee J, Mitchell A, et al. US‐guided treatment for chronic Achilles tendinopathy: an update and current status. Skeletal Radiology. 2010;39:425‐434.
  20. ↑ Yelland, M. J., Sweeting, K. R., Lyftogt, J. A., Ng, S. K., Scuffham, P. A., & Evans, K. A. (2011). Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med, 45(5), 421-428. doi: 10.1136/bjsm.2009.057968
  21. ↑ De Vos R, Weir A, et al. PRP injection for chronic Achilles tendinopathy. Journal of the American Medical Association. 2010;303(3):144‐149.
  22. ↑ Engebretsen L, Steffen K, et al. IOC consensus paper on use of PRP in sports medicine. British Journal of Sports Medicine. 2010;44(15):1072‐1081.
  23. ↑ De Jonge S, de Vos R, Weir A, et al. 1‐year follow‐up of PRP treatment in chronic Achilles tendinopathy: a double‐blind random placebo‐controlled trial. American Journal of Sports Medicine. 2011;39(8):1623‐1629.
  24. ↑ Bell, K. J., Fulcher, M. L., Rowlands, D. S., & Kerse, N. (2013). Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial (Vol. 346).
  25. ↑ Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disability and Rehabilitation. 2008;30:1697‐1708.
  26. ↑ Maffulli, N., Spiezia, F., Longo, U. G., Denaro, V., & Maffulli, G. D. (2013). High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Physical Therapy in Sport, 14(3), 163-167. doi: http://dx.doi.org/10.1016/j.ptsp.2012.07.002
  27. ↑ Boesen, A., Boesen, M., Hansen, R., Malliaras, P., Chan, O., & Langberg, H. (2014). 61 High Volume Injection, Platelet Rich Plasma And Placebo In Chronic Achilles Tendinopathy–A Double Blind Prospective Study. British Journal of Sports Medicine, 48(Suppl 2), A39-A40.
  28. ↑ Housner J, Jacobsen J, Misko R. Sonographically guided percutaneous needle tenotomy for treatment of chronic tendinosis. Journal of Ultrasound Medicine. 2009;28(8):1187‐1192.
  29. ↑ Testa V, Capasso G, Benazzo F, Muffulli N. Management of Achilles tendinopathy by US‐guided percutaneous tenotomy. Medicine and Science in Sports and Exercise. 2002;34(4):573‐580.
  30. ↑ Maffulli, N., Oliva, F., Testa, V., Capasso, G., & Del Buono, A. (2013). Multiple Percutaneous Longitudinal Tenotomies for Chronic Achilles Tendinopathy in Runners A Long-Term Study. The American journal of sports medicine, 41(9), 2151-2157.
  31. ↑ Tallon C, Coleman B, Khan K, Maffulli N. Outcomes of surgery of chronic Achilles tendinopathy. Am J Sports Med. 2001;29(3):315‐320.
  32. ↑ Maffulli, N., Del Buono, A., Testa, V., Capasso, G., Oliva, F., & Denaro, V. (2011). Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision. Journal of Bone & Joint Surgery, British Volume, 93(11), 1503-1507.
  33. ↑ Longo UG, Ramamurthy C, Denaro V, Maffulli N. Minimally invasive stripping for chronic Achilles tendinopathy. Disabil Rehabil. 2008;30(20‐22):1709‐13.

Acknowledgements[edit | edit source]

Developed by Michael Yates, PT. BC Physiotherapy Tendinopathy Task Force. April 2012.

Updated by Alexandra Kobza, Dr. Alex Scott. June 2015.

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