Achilles Tendinopathy Toolkit: Section F - Medical and Surgical Interventions

Achilles Tendinopathy: Medical and Surgical Interventions

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 more strongly supported conservative management strategies (see “Achilles Tendinopathy: Summary of the Evidence for Physical Therapy Interventions”).

Pharmacological Approaches

NSAIDS

Method		Short term benefit in the acute stage of tendinopathy to minimise inflammatory process.
Proposed Mechanism		Interrupts the chemical pathway of inflammation.
Benefit: Pros/Cons	Pros:	Inexpensive, easily accessible.
	Cons:	Precautions and contraindications that accompany specific medications. Inhibition of inflammation may delay soft tissue repair by impairing fibroblastic proliferation.
Evidence		Limited evidence for a modest effect of topical or oral NSAIDs in acute stage in Achilles tendinopathy.
Take Home Message '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)

Method		Short‐term benefit in acute stage. In chronic tendinopathy, the role of inflammation is unclear, and the rationale for the use of anti‐inflammatory injections is controversial. Many studies report an absence of cellular features of inflammation in chronic tendinopathy.
Proposed Mechanism		Injection into the paratendon to interrupt the inflammatory process.
Benefit: Pros/Cons	Pros:	Easily accessible. Careful administration outside the structure of the tendon is considered ‘safe’ i.e., in the paratendon sheath.
	Cons:	Invasive, painful. Risk of infection (1%) ‘universal precautions’ required. Destructive; risk of tendon rupture; impairs tissue repair mechanism.
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.
Take Home Message '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)

Method		Nitro‐glycerine patches applied over tendon to enhance healing.
Proposed Mechanism		Nitric oxide may increase blood flow to the tendon and stimulate repair by enhancing fibroblast proliferation.
Benefit: Pros/Cons	Pros:	GTN improves 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.
Evidence		Conflicting evidence limits conclusions and widespread use.
Take Home Message 'Implications for Physiotherapy		If prescribed by a physician, may be applied by a physiotherapist and used in conjunction with an eccentric exercise program.

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• Click to go back to: Appendix C: Details of Articles on Interventions

Injection Therapies

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.

Polidocanol

Method		Originally developed as an anaesthetic, and widely used as a sclerosing agent in the treatment of varicose veins.
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.
Benefit: Pros/Cons	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.
Evidence		Conflicting evidence limits conclusions and widespread use.
Take Home Message '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

Method		Injection of hyperosmolar dextrose with small amount of anaesthetic to induce a ‘pro‐inflammatory’ proliferative cell response.
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.
Benefit: Pros/Cons	Pros:	Can be performed with or without US‐guided localisation. US‐guided technique permits localization to a specific target site. However, injections without US imaging may also be effective, even in a subcutaneous approach superficial to the target tissue.
	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, similar to other injection therapies. Expensive sonography equipment requiring an experienced operator.
Evidence		Prolotherapy combined with eccentric exercise for Achilles tendon loading provides more rapid improvement in symptoms than eccentrics alone, although long‐term VISA‐A scores are similar.
Take Home Message 'Implications for Physiotherapy		Prolotherapy may enhance outcomes compared to using eccentric exercise, alone.

Platelet Rich Plasma (PRP) and Autologous whole blood

Method		Centrifuge of autologous blood to collect a concentrate of the platelets and plasma. This is then injected back into the patient’s tendon.
Proposed Mechanism		Cellular and humoral (blood) mediators promote healing in areas of tendon degeneration.
Benefit: Pros/Cons	Pros:	Growing interest in PRP (platelet rich plasma).
	Cons:	Requires expensive blood processing equipment and centrifuge. Also, it is a US-guided technique requiring sonography and an experienced operator.
Evidence		A single RCT demonstrated no benefit of PRP compared to saline injections in AT. A consensus panel from the International Olympic Committee (IOC) recommended that physicians should proceed with caution using PRP in sports medicine (including Achilles tendon injuries).
Take Home Message 'Implications for Physiotherapy		PTs are part of a treatment team when treating tendon injury. General knowledge of PRP, PRGF and PDGF is important to assist patients in decision-making.

High volume injection (HVI) or Hydrostatic dissection

Method		Small volume of anaesthetic/steroid and high volume of saline, delivered by US‐guided imaging.
Proposed Mechanism		The pressure created by the volume of substance into the tendon sheath is proposed to disrupt the neovessel ingrowth in Achilles tendinopathy.
Benefit: Pros/Cons	Pros:	Non‐surgical option.
	Cons:	Requires sonography equipment.
Evidence		Potential treatment option for Achilles tendinopathy that has failed to respond to a more conservative approach.
Take Home Message 'Implications for Physiotherapy		Provides another treatment option when conservative treatment has been unsatisfactory.

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• Click to go back to the Treatment Algorithm
• Click to go back to the Summary of Interventions
  
• Click to go back to Appendix A: Exercise Programs
• Click to go back to Appendix B: Low Level Laser Therapy Dosage Calculation
• Click to go back to: Appendix C: Details of Articles on Interventions

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")

Method		Tissue trauma from the cutting edge of the needle/lumen.
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).
Benefit: Pros/Cons	Pros:	Invasive treatment that avoids full surgical exposure and risks.
	Cons:	Requires sonography equipment.
Evidence		Needling alone without injection of a substance has shown a positive result for improving pain without complications.
Take Home Message 'Implications for Physiotherapy		Provides another treatment option for clients that have failed to respond to other conservative treatment.

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• Click to go back to the Treatment Algorithm
• Click to go back to the Summary of Interventions
  
• Click to go back to Appendix A: Exercise Programs
• Click to go back to Appendix B: Low Level Laser Therapy Dosage Calculation
• Click to go back to: Appendix C: Details of Articles on Interventions

Surgical Approaches

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

Percutaneous tenetomy

Method		Techniques include closed dissection of the tendon sheath by US‐guided percutaneous longitudinal internal tenotomy; or open surgical exposure of the tendon, followed by multiple longitudinal splitting of the tendon.
Proposed Mechanism		Surgical trauma creates granulation and repair, and interrupts fibrous adhesions.
Benefit: Pros/Cons	Pros:	Simple procedure that can be done as an outpatient. Short recovery compared to more invasive surgery.
	Cons:	Risk of infection.
Evidence		Satisfactory outcomes for selected patients that do not have complicated Achilles pathology, and have failed to respond to a conservative treatment approach.
Take Home Message 'Implications for Physiotherapy		PT may be involved in the post‐op rehabilitation following surgery.

Surgical debridement

Method		Central longitudinal incision to expose the tendon, with excision of disorganised and fibrotic tendon tissue and adhesions. Additional diathermy to destroy neovessels.
Proposed Mechanism		Surgery creates granulation and repair, and removes fibrotic tissue.
Benefit: Pros/Cons	Pros:	High success rates reported by some centres.
	Cons:	Risk of infection. Long post‐op recovery of 3‐6 months.
Evidence		Surgery may be a successful option for patients that have failed to respond to conservative treatment, or have complicated Achilles tendon pathology.
Take Home Message 'Implications for Physiotherapy		PT may be involved in the post‐op rehabilitation following surgery.

Minimally invasive stripping

Method		Small incision is made allowing a probe or scalpel to be inserted ventral to the tendon. The area of neovascularisation is stripped.
Proposed Mechanism		Disrupts abnormal blood/nerve supply, releases adhesions.
Benefit: Pros/Cons	Pros:	High success rates reported. Minimal trauma to tendon. Quick return to sport.
	Cons:	Risk of infection. Potential loss of gliding function due to long term increased fibrosis around tendon.
Evidence		Retrospective, short‐term studies only.
Take Home Message 'Implications for Physiotherapy		PT may be involved in the post‐op rehabilitation following surgery.

• Click to go back to the contents page
• Click to go back to the Treatment Algorithm
• Click to go back to the Summary of Interventions
  
• Click to go back to Appendix A: Exercise Programs
• Click to go back to Appendix B: Low Level Laser Therapy Dosage Calculation
• Click to go back to: Appendix C: Details of Articles on Interventions
  

Download Achilles Tendinopathy Toolkit: Appendix D

File:Download Appendix D - Medical and Surgical Interventions.pdf

Acknowledgements

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