Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol

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.     

Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2-year follow-up

The short-term results after treatment with sclerosing polidocanol injections have been shown to be good in patients with chronic painful mid-portion Achilles tendinosis. This study aimed to evaluate the longer-term effects on tendon thickness, structure and vascularity, patient satisfaction with treatment, and pain during tendon loading activity. Ultrasonography (US) + colour Doppler (CD) was used for evaluation of the tendon, and the patients graded the amount of pain during tendon loading activity on a VAS. Forty-two patient’s tendons (23 men and 19 women, mean age 53 years) with a long duration (mean 32 months) of pain symptoms from mid-portion Achilles tendinosis (US + CD showed a localised thickening, structural changes and neovascularisation), were at three (mean) occasions (6–8 weeks in between) treated with US and CD guided injections of the sclerosing substance polidocanol, targeting the area with neovessels ventral to the tendon. After treatment, 37 patients were satisfied with the results of the treatment and back to previous (before injury) activity level. At the 2-year follow-up (mean 23 months), 38 patients were satisfied with the results of the treatment, and there was a significant reduction in VAS (from 75 to 7; P < 0.05). US showed a significant reduction in the mean mid-portion tendon thickness (from 10 to 8 mm, P < 0.05) and a “more normal” structure. CD showed no, or a few, remaining neovessels in the majority of the successfully treated tendons. In conclusion, treatment with sclerosing polidocanol injections in patients with chronic painful mid-portion Achilles tendinosis showed remaining good clinical results at a 2-year follow-up. Decreased tendon thickness and improved structure after treatment, might indicate a remodelling potential?     

Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment

BACKGROUND: The mechanism that causes pain in chronic Achilles tendinosis is not known. However, high resolution colour Doppler ultrasound has shown that neovascularisation may be involved. OBJECTIVE: To investigate if sclerosing the neovessels would affect the level of tendon pain. METHODS: The effect of colour Doppler ultrasound guided injection of a sclerosing agent, polidocanol, against neovessels was studied in 10 patients (seven men and three women, mean age 55 years) with painful chronic mid-portion Achilles tendinosis. RESULTS: Eight patients were satisfied with the results of treatment. There was significantly reduced pain during activity (reported on a visual analogue scale (VAS)) and no remaining neovascularisation after an average of two injections. Two patients were not satisfied, and neovascularisation remained. At the six month follow up, the same eight patients remained satisfied and could perform Achilles tendon loading activities as desired. Their VAS score had decreased from 74 before treatment to 8 (p<0.01). CONCLUSIONS: Sclerosing neovessels appears to be an effective treatment for painful chronic Achilles tendinosis, suggesting that neovessels play a key part in causing chronic tendon pain.     

The chronic painful Achilles and patellar tendon: research on basic biology and treatment

The etiology and pathogenesis of chronic tendon pain are unknown. Even though tendon biopsies having shown an absence of inflammatory cell infiltration, anti-inflammatory agents (non-steroidal anti-inflammatory drugs, corticosteroidal injections) are commonly used. We have demonstrated that it is possible to use intratendinous microdialysis to investigate human tendons, and found normal prostaglandin E2 (PGE2) levels in chronic painful tendinosis (Achilles and patellar) tendons. Furthermore, gene technological analyses of biopsies showed no upregulation of pro-inflammatory cytokines. These findings show that there is no PGE2-mediated intratendinous inflammation in the chronic stage of these conditions. The neurotransmitter glutamate (a potent modulator of pain in the central nervous system) was, for the first time, found in human tendons. Microdialysis showed significantly higher glutamate levels in chronic painful tendinosis (Achilles and patellar) tendons, compared with pain-free normal control tendons. The importance of this finding is under evaluation. Treatment is considered to be difficult, and not seldom, surgery is needed. However, recent researches on non-surgical methods have shown promising clinical results. Painful eccentric calf-muscle training has been demonstrated to give good clinical short- and mid-term results on patients with chronic painful mid-portion Achilles tendinosis. Good clinical results were associated with decreased tendon thickness and a structurally more normal tendon with no remaining neovessels. Using ultrasonography (US)+color Doppler (CD), and immunhistochemical analyses of biopsies, we have recently demonstrated a vasculo/neural (Substance-P and Calcitonin Gene-Related Peptide nerves) ingrowth in the chronic painful tendinosis tendon, but not in the pain-free normal tendon. A specially designed treatment, using US- and CD-guided injections of the sclerosing agent Polidocanol, targeting the neovessels outside the tendon, has been shown to cure tendon pain in pilot studies, in a majority of the patients. A recent, randomized, double-blind study verified the importance of injecting the sclerosing substance Polidocanol.     

Neovascularisation in chronic painful patellar tendinosis—promising results after sclerosing neovessels outside the tendon challenge the need for surgery

Sclerosing injections targeting neovascularisation have been demonstrated to give promising clinical results in patients with chronic painful Achilles tendinosis. In this study, fifteen elite or recreational athletes (12 men and three women) with the diagnosis patellar tendinosis/Jumpers knee in 15 patellar tendons were included. All the patients had a long duration of pain symptoms (mean = 23 months) from the patellar tendon, and ultra-sonography + colour doppler examination showed structural tendon changes with hypo-echoic areas and a neovascularisation, corresponding to the painful area. The patients were treated with ultrasound and colour doppler-guided injections of the sclerosing substance Polidocanol, targeting the area with neovascularisation. At follow-up (mean = 6 months) after a mean amount of three treatments, there was a good clinical result in 12/15 tendons. The patients were back to their previous (before injury) sport activity level, and the amount of pain recorded on a VAS-scale had decreased significantly (VAS from 81 to 10). Our findings indicate that treatment with sclerosing injections, targeting the area with neovessels in patellar tendinosis, has the potential to cure the pain in the tendons and also allow the patients to go back to full patellar-tendon loading activity.     

No beneficial effect of Polidocanol treatment in Achilles tendinopathy: a randomised controlled trial

Purpose

Polidocanol injections have been used to treat chronic Achilles tendinopathy in clinical settings, but the few studies published show inconsistent results. The aim of this study was to evaluate the mid-term effect of Polidocanol in patients with chronic Achilles tendinopathy. It was hypothesised that patients treated with Polidocanol would have significant improvements in the outcome measures investigated compared to patients treated with a placebo treatment at mid-term follow-up.

Methods

This randomised controlled trial included forty-eight patients aged 32–77 years with a history of Achilles tendinopathy for at least 3 months and with neovascularisation demonstrated by ultrasonography was included. A minimum of 3 months of eccentric exercise treatment was required before participating. The patients were allocated to a maximum of two injection of either Polidocanol or Lidocaine (placebo). The primary outcome measure was pain during walking reported on a visual analogue scale. Secondary outcome measures were Foot and Ankle Outcome Score (FAOS), patient satisfaction with treatment and, shortly after inclusion, the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A) was also included. Follow-up examinations were performed after 3 and 6 months.

Results

Pain during walking decreased during the 6-month follow-up period, but no significant differences were seen between the two groups. The same tendency was seen for FAOS and VISA-A in which both groups showed an improvement at 3- and 6-month follow-up, but no mid-term differences between the groups were seen. An equal number of patients in the two groups were satisfied with the treatment at follow-up.

Conclusions

The results indicate that Polidocanol is a safe treatment, but the mid-term effects are the same as a placebo treatment. This further questions the use of Polidocanol in the treatment of chronic Achilles tendinopathy.

Level of evidence

I.

     

Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study

Background

High resolution colour Doppler ultrasound shows intratendinous Doppler activity in patients with chronic Achilles tendinopathy. Treatment of this neovascularisation with sclerosing therapy seems to relieve the pain. However, the procedure often has to be repeated.

Objective

To investigate the effect of electrocoagulation of the neovessels on tendon pain and tendon vascularity in patients with chronic Achilles tendinopathy.

Methods

Colour Doppler ultrasound guided electrocoagulation was used on vessels in the ventral portion of the Achilles tendon in 11 patients (seven men, four women, mean age 41 years) with painful chronic mid‐portion Achilles tendinosis. A unipolar coagulation device was used.

Results

One patient dropped out after two months (dissatisfied with the results). The remaining 10 patients (91%) were satisfied. These 10 patients were still satisfied at six months of follow up and had returned to their previous level of activity. All 10 patients were “cured” after one treatment. The patient who dropped out received two treatments because of lack of progress. There was significantly reduced pain (Likert pain scale, 0–10) during activity, from a median of 7 (range 4 to 10) at baseline to 0 (0 to 8) at six months'' follow up (p<0.005); and at rest, from 1.5 (1 to 5) to 0 (0 to 8) (p = 0.005). In all patients, vascularisation was unchanged at the six months follow up, with no significant change in semiquantitative or quantitative colour scoring.

Conclusions

Coagulation in the area with vessels entering the tendon appears to be effective treatment for painful chronic mid‐tendinous Achilles tendinopathy. No effect on the intratendinous Doppler activity could be detected, suggesting that the effect is independent of changes in blood flow. Localisation of hyperaemia appears to be the key to the pathology and for targeting the treatment. One explanation could be that the effect is obtained by destruction of nerves accompanying the vessels.     

Treatment of midportion Achilles tendinosis: similar clinical results with US and CD-guided surgery outside the tendon and sclerosing polidocanol injections

Sclerosing polidocanol injections targeting the area with vasculo/neural ingrowth on the ventral side of the tendon have previously been demonstrated to give good clinical results in patients with chronic painful midportion Achilles tendinosis. In this study, 20 consecutive patients (9 men and 11 women, mean age 46 years) with chronic painful midportion Achilles tendinosis were treated with either sclerosing polidocanol injections (Group A) or open surgical revision of the area with vasculo/neural ingrowth on the ventral side of the Achilles tendon (Group B). Before treatment, all patients had structural tendon changes and increased blood flow-neovascularisation demonstrated with US and colour Doppler. Under US and colour Doppler-guidance, both the injections and the surgical revision targeted the area with neovessels just outside the ventral part of the tendon. A maximum of two sclerosing injection treatments, with 6–8 weeks in-between, were given. For evaluation, the patients recorded the severity of Achilles tendon pain during tendon loading activity (their recreational or sport activity), before and after treatment, on a VAS. Patient global satisfaction with treatment was also assessed. At the 3 months follow-up 6/9 (one patient was excluded) patients in Group A, and 8/10 patients in Group B, were satisfied with the treatment and had a significantly reduced level of tendon pain (Group A VAS from 76 to 24, P < 0.05, Group B VAS from 75 to 21, P < 0.05). There was one deep infection in Group B. At the 6 months follow-up, 6/9 patients in Group A, and 10/10 patients in Group B were satisfied. In summary, both treatment with sclerosing polidocanol injections and open surgical revision outside the ventral Achilles midportion show promising short-term clinical results.     

Endoscopic treatment of chronic mid-portion Achilles tendinopathy: novel technique with short-term results

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.     

Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?

The background to the good clinical results reported using painful eccentric calf-muscle training as treatment for chronic painful mid-portion Achilles tendinosis is not known. Recently, using ultrasound and colour Doppler technique, we showed that painful tendinosis was associated with a local neovascularisation. Furthermore, in a pilot study, destroying these neovessels by sclerosing therapy cured the pain in most patients. Dynamic ultrasound and colour Doppler examination has shown that the flow in the neovessels stops during dorsiflexion in the ankle joint. Therefore, it was of interest to study the occurrence of neovascularisation before and after eccentric training. Forty-one tendons in 30 patients (22 men and 8 women, mean age 48 years) with chronic painful mid-portion Achilles tendinosis were examined with ultrasonography and colour Doppler, before and after 12 weeks of eccentric calf-muscle training. Before treatment, there was a local neovascularisation in the area with tendon changes (hypo-echoic areas, irregular fibre structure) in all tendons. At follow-up after treatment (mean 28 months), there was a good clinical result (no tendon pain during activity) in 36/41 tendons, and a poor result in 5/41 tendons. In 34/36 tendons with a good clinical result of treatment there was a more normal tendon structure, and in 32/36 tendons there was no remaining neovascularisation. In 5/5 tendons with a poor clinical result there was a remaining neovascularisation in the tendon, and in 2/5 tendons there were remaining structural abnormalities. In conclusion, in patients with chronic painful mid-portion Achilles tendinosis, a good clinical result after eccentric training seems to be associated with a more normal tendon structure and no remaining neovascularisation. Action on the area with neovessels during the eccentric training regimen might possibly be responsible for the good clinical results.     

Magnetic resonance signal, rather than tendon volume, correlates to pain and functional impairment in chronic Achilles tendinopathy

PURPOSE: To depict abnormal tendon matrix composition using magnetic resonance imaging (MRI) in chronic Achilles tendinopathy, and correlate intratendinous signal alterations to pain and functional impairment. MATERIAL AND METHODS: MRI of the Achilles tendon was performed on 25 patients with chronic Achilles tendinopathy (median age 50, range 37-71 years). All patients suffered from pain in the mid-portion of the Achilles tendon. Intratendinous signal was calculated from five different sagittal sequences, using a computerized 3D seed-growing technique. Pain and functional impairment were evaluated using a questionnaire completed by patients. RESULTS: Severity of pain and functional impairment correlated to increased mean intratendinous signal in the painful tendon in all MR sequences (P < 0.05, median r = 0.38, range 0.28-0.43 for pain; P < 0.05, median r = 0.48, range 0.29-0.49 for functional impairment). However, tendon volume did not correlate to pain or functional impairment (P > 0.05). Difference in mean intratendinous signal between symptomatic and contralateral asymptomatic tendons was highly significant in all sequences (P < 0.05) except on T2-weighted images (P = 0.6). CONCLUSION: Severity of pain and disability correlated to increased MR signal rather than to tendon volume in patients with unilateral mid-portion chronic Achilles tendinopathy.     

Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy

Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented.     

Microcirculatory effects of topical glyceryl trinitrate on the Achilles tendon microcirculation in patients with previous Achilles tendon rupture

Topical glyceryl trinitrate treatment has demonstrated short- to mid-term efficacy in chronic noninsertional Achilles tendinopathy. However, the underlying mechanisms are far from being understood. We hypothetized that Achilles tendon capillary blood flow changes immediately after topical glyceryl trinitrate treatment. Fifteen patients (55 ± 15 years, VAS 5.8 ± 2.3) with current mid-portion Achilles tendon pain 36 months after open surgical Achilles tendon repair for tendon rupture were included. On the Achilles mid-portion, 1.2 mg topical glyceryl trinitrate was sprayed. Microcirculatory monitoring included capillary blood flow, tendon oxygen saturation and postcapillary venous filling pressures at the insertion and 2, 4 and 6 cm above the insertion using a combined laser Doppler and spectrophotometry system. Baseline capillary blood-flows of the painful versus the uninjured tendon were increased [108 ± 46 vs. 81 ± 20 (2 cm above the insertion), 104 ± 40 vs. 76 ± 20 (4 cm above the insertion), 111 ± 53 vs. 90 ± 21 (6 cm above the insertion, P < 0.05)]. However, topical glyceryl trinitrate did not change capillary blood-flow at 2 and 8-mm tissue depths at the painful Achilles tendon or the healthy tendon. Tendon oxygenation was not changed at the painful or the healthy Achilles tendon. Postcapillary venous filling pressure was reduced at 8 mm at the mid-portion in the painful Achilles tendon only (113 ± 37 vs. 95 ± 31, P = 0.030). Acute topical glyceryl trinitrate facilitates capillary venous outflow in painful Achilles tendons. However, capillary blood-flow and tendon oxygenation remain unchanged following acute topical glyceryl trinitrate application. Elevated capillary blood-flow at the entire mid-portion is encountered at baseline in previously ruptured painful Achilles tendons even 3 years after surgical repair of the Achilles tendon indicating an altered microcirculatory flow pattern.     

Chronic Achilles tendon pain treated with eccentric calf-muscle training

Injuries involving the Achilles tendon and manifested as chronic tendon pain are common, especially among recreational athletes. In a pilot study on a small group of patients with chronic painful mid-portion Achilles tendinosis, eccentric calf-muscle training was shown to give good clinical results. The aim of this prospective study was to investigate if the previously achieved good clinical results could be reproduced in a larger group of patients, and also to investigate the effects of eccentric calf-muscle training in patients with chronic insertional Achilles tendon pain. Seventy-eight consecutive patients, having chronic painful Achilles tendinosis at the mid-portion (2–6 cm level) in a total of 101 tendons (55 unilateral and 23 bilateral), and thirty consecutive patients with chronic insertional Achilles tendon pain in 31 tendons (29 unilateral and one bilateral) were treated with eccentric calf-muscle training for 12 weeks. Most patients were recreational athletes. Evaluation of the amount of tendon pain during activity was recorded on a visual analogue scale (VAS), before and after treatment. In 90 of the 101 Achilles tendons (89%) with chronic painful mid-portion Achilles tendinosis, treatment was satisfactory and the patients were back on their pre-injury activity level after the 12-week training regimen. In these patients, the amount of pain during activity, registered on the VAS-scale (mean±SD), decreased significantly from 66.8±19.4 to 10.2±13.7. On the contrary, in only ten of the tendons (32%) with chronic insertional Achilles tendon pain was treatment satisfactory, with a significant decrease on the VAS-scale (mean±SD), from 68.3±7.0 to 13.3±13.2. Our conclusion is that treatment with eccentric calf-muscle training produced good clinical results in patients with chronic painful mid-portion Achilles tendinosis, but not in patients with chronic insertional Achilles tendon pain.     

Sclerosing polidocanol injections to treat chronic painful shoulder impingement syndrome-results of a two-centre collaborative pilot study

The histological changes found in the supraspinatus tendon have similarities with the findings in Achilles-, patellar- and extensor carpi radialis brevis (ECRB)-tendinopathy. In recent studies, we have found a vasculo-neural ingrowth in chronic painful Achilles and patellar tendinopathy, and demonstrated good short-term clinical effects with injections of the sclerosing substance polidocanol. In this collaborative two-centre pilot study, 15 patients (10 males and 5 females, mean age 46 years) with a long duration of shoulder pain (mean 28 months), and given the diagnosis chronic painful shoulder impingement syndrome, were included. They had tried rest, traditional rehabilitation exercises and multiple subacromial corticosteroid injections, without effect. We found vascularity (neovessels) in chronic painful, but not in pain-free, supraspinatus tendons, and prospectively studied the clinical effects of ultrasound (US) and colour Doppler (CD)-guided injections of polidocanol, targeting the area with neovessels. The patients evaluated the amount of shoulder pain during horizontal shoulder activity on a visual analogue scale (VAS), and satisfaction with treatment. Two (median) (range 1–5) polidocanol treatments (with 4–8 weeks in between) were given. In four patients (considered treatment failure), cortisone was injected into an inflamed subacromial bursa at one separate occasion weeks after the last polidocanol injection. At follow-up, 8 (median) (range 4–17) months after the treatment, 14 patients were satisfied with the result. Using the visual analogue scale evaluation (VAS), the pain dropped from 79 before treatment to 21 at follow-up (P < 0.05). In the short-term perspective, sclerosing polidocanol injections targeting the neovessels in the supraspinatus tendon and/or bursa wall seems to have a potential to reduce the pain during shoulder loading activity.     

Sclerosing therapy in chronic Achilles tendon insertional pain-results of a pilot study

The origin of Achilles tendon insertional pain has not been clarified. Treatment is considered difficult, though tendon, bone, and bursae, alone or in combination, may all be the source of pain. Recently, neovascularisation in the area with tendon changes was shown to correlate with pain in patients with chronic mid-portion Achilles tendinosis. In a pilot study, sclerosing the neovessels outside the tendon cured the pain in the majority of patients. In this pilot-study, ultrasonography and colour Doppler was used for the investigation of eleven patients (nine men and two women, mean age 44 years) with a long duration (mean 29 months) of chronic Achilles tendon insertional pain. All patients had distal tendon changes and a local neovascularisation inside and outside the distal tendon on the injured/painful side, but not on the noninjured/pain-free side. In nine patients there was also a thickened retrocalcaneal bursae, and in four patients also bone pathology (calcification, spur, loose fragment) in the insertion. The sclerosing agent polidocanol was injected against the local neovessels found in all patients. At follow-up (mean eight months), sclerosing of the area with neovessels had cured the pain in eight out of eleven patients, and in seven of the eight patients there was no neovascularisation. Pain during tendon-loading activity, recorded on a VAS-scale, decreased from 82 mm before treatment to 14 mm after treatment in the successfully treated patients. In conclusion, treatment only focusing on sclerosing the area with neovessels showed promising short-term clinical results in this small pilot study. The findings support further studies, preferably in a randomised manner.     

Is vasculo-neural ingrowth the cause of pain in chronic Achilles tendinosis?

The purpose of this study was to investigate where the pain comes from in chronic mid-portion Achilles tendinosis, by using ultrasonography and colour Doppler, immunohistochemistry, and diagnostic injections. Twenty-five tendons in 24 patients (mean age 47 years) with the clinical diagnosis of painful chronic mid-portion Achilles tendinosis, and 20 tendons in 14 controls (mean age 48 years) with pain-free Achilles tendons were examined with ultrasonography and colour Doppler. For the 25 painful tendons, a local anaesthetic was injected in the area with neovascularisation outside the ventral part of the tendon. Biopsies taken from tendinosis tissue in six patients were used for PGP 9.5 immunohistochemistry. A neovascularisation, inside and outside the ventral part of the area with tendon changes, was demonstrated in all painful tendinosis tendons, but not in any of the pain-free control tendons. After injection of the local anaesthetic towards the neovessels outside the ventral part of the tendon, the pain during tendon-loading activity was temporarily cured in all patients. The mean VAS-score for heel-raises decreased significantly from 75 mm to 6 mm. In biopsies, PGP 9.5 immunohistochemistry showed nerve structures in the vicinity of blood vessels. In conclusion, we demonstrate findings which support neovessels and accompanying nerves being the possible source of pain in chronic mid-portion Achilles tendinosis.     

Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomized controlled trial

BACKGROUND: Color Doppler ultrasound examination frequently reveals neovascularization in chronic painful Achilles and patellar tendinopathy. Sclerosing the area with vascular ingrowth using polidocanol has shown promising clinical results in patients with Achilles tendinopathy. PURPOSE: To investigate sclerosing treatment using polidocanol on a group of elite athletes with patellar tendinopathy. STUDY DESIGN: Randomized controlled trial/cross-over study; Level of evidence, 1. METHODS: The authors recruited 33 patients (42 tendons), mainly from the Norwegian elite divisions in basketball, team handball, and volleyball. Seventeen patients (23 knees) were randomized to the treatment group (polidocanol injections in the area of neovascularization) and 16 patients (20 knees) to the control group (similar injections with lidocaine/epinephrine). After 4 months of treatment, the control group was crossed over to active treatment. Pain and function were recorded using the Victorian Institute of Sport Assessment score before the start of treatment and 4, 8, and 12 months after the first injection. Victorian Institute of Sport Assessment scores between groups were compared using multivariate analysis of variance for repeated measures. RESULTS: The treatment group reported a significant improvement in Victorian Institute of Sport Assessment score from 51 to 62 after 4 months; there was no change for the control group (group by time interaction, P = .052). After 8 months, when the control group had also received active treatment with polidocanol, they had a greater improvement in Victorian Institute of Sport Assessment score (58-79) than did the treatment group (54-70; group by time interaction, P = .022; time effect, P < .0001). There was no further time or group effect in Victorian Institute of Sport Assessment score to the 12-month follow-up (treatment, 72; control, 85). CONCLUSION: Sclerosing injections with polidocanol resulted in a significant improvement in knee function and reduced pain in patients with patellar tendinopathy.     

Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up

OBJECTIVE: To prospectively investigate tendon thickness and tendon structure by ultrasonography in patients treated with eccentric calf muscle training for painful chronic Achilles tendinosis located at the 2-6 cm level in the tendon. METHODS: The patients were examined with grey scale ultrasonography before and 3.8 years (mean) after the 12 week eccentric training regimen. At follow up, a questionnaire assessed present activity level and satisfaction with treatment. RESULTS: Twenty six tendons in twenty five patients (19 men and six women) with a mean age of 50 years were followed for a mean of 3.8 years (range 1.6-7.75). All patients had a long duration of painful symptoms (mean 17.1 months) from chronic Achilles tendinosis before treatment. At follow up, 22 of 25 patients were satisfied with treatment and active in Achilles tendon loading activities at the desired level. Ultrasonography showed that tendon thickness (at the widest part) had decreased significantly (p<0.005) after treatment (7.6 (2.3) v 8.8 (3) mm; mean (SD)). In untreated normal tendons, there was no significant difference in thickness after treatment (5.3 (1.3) mm before and 5.9 (0.8) mm after). All tendons with tendinosis had structural abnormalities (hypoechoic areas and irregular structure) before the start of treatment. After treatment, the structure was normal in 19 of the 26 tendons. Six of the seven patients with remaining structural abnormalities experienced pain in the tendon during loading. CONCLUSIONS: Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon.     

Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes

BACKGROUND: Neovascularisation can be detected qualitatively by Power Doppler in Achilles tendinopathy. Quantitative data regarding tendon microcirculation have not been established and may be substantial. PURPOSE: To assess the microcirculation of the Achilles tendon and the paratendon in healthy volunteers as well as in athletes with either midportion or insertional tendinopathy. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In 66 physically active volunteers, parameters of Achilles tendon and paratendon microcirculation, such as tissue oxygen saturation, relative postcapillary venous filling pressures, and microcirculatory blood flow, were determined at rest at 2-mm and 8-mm tissue depths. Forty-one patients never had Achilles pain (25 men, 27 +/- 8 years), 14 patients had insertional pain (7 men, 29 +/- 8 years), and 11 patients had midportion tendinopathy (7 men, 38 +/- 13 years, not significant). RESULTS: Achilles tendon diameter 2 cm and 6 cm proximal to the insertion was increased in symptomatic tendons. Compared with the uninvolved opposite tendon, deep microcirculatory blood flow was significantly elevated at insertional (160 +/- 79 vs 132 +/- 42, P < .05) as well as in midportion tendinopathy (150 +/- 74 vs 119 +/- 34, P < .05). The microcirculation in the uninvolved opposite tendon and the normal athlete controls were not significantly different from each other (132 +/- 42 insertional asymptomatic vs 119 +/- 34 mid-portion vs 120 +/- 48 healthy tendon). Insertional paratendon deep microcirculatory flow was elevated in all groups, whereas tissue oxygen saturation and relative postcapillary venous filling pressures were not significantly different. CONCLUSION: Microcirculatory blood flow is significantly elevated at the point of pain in insertional and midportion tendinopathy. Postcapillary venous filling pressures are increased at both the midportion Achilles tendon and the midportion paratendon, whereas tissue oxygen saturation is not different among the studied groups. We found no evidence of an abnormal microcirculation of the asymptomatic limb in Achilles tendinopathy.