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?     

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 injections in midportion Achilles tendinopathy: a retrospective study of 25 patients

Sclerosing injections under ultrasonographic guidance is a new method of treatment for persistent pain in Achilles tendinosis. Good results, even superior to those of surgery, have been described. We report the outcome of 25 patients with midportion tendinosis receiving sclerosing treatment. Twenty-eight consecutive patients (29 tendons) with ultrasonographical findings of midportion tendinosis examined during the period November 2004 to November 2005 were identified in the database of the Department of Radiology, Malmö University Hospital. Twenty-five patients (26 tendons) were found suitable for treatment. Follow-up consisted of self-assessment questionnaire or phone interview. In 19 patients (20 tendons), results were good or excellent. Complications were few and mild. We conclude that sclerosing injections is a promising alternative to surgery in chronic Achilles midportion tendinosis. Our results are comparable to those obtained with surgery, but the procedure is less invasive. However, a few cases of tendinosis lack detectable neovessels and may still be candidates for surgery.     

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 injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: a double-blind randomised controlled trial

Local injections of the sclerosing substance Polidocanol has been demonstrated to give good clinical results in a pilot study on patients with chronic Achilles tendinopathy. In this study, 20 consecutive patients (9 men and 11 women, mean age 50 years) with chronic painful mid-portion Achilles tendinopathy were randomised to injection treatment with either Polidocanol (5 mg/ml) (group A) or Lidocaine hydro-chloride (5 mg/ml) + Adrenaline (5 g/ml) (group B). Both substances have a local anaesthetic effect, but Polidocanol also has a sclerosing effect. The patients and the treating physician were blinded to the substance injected. The short-term effects were evaluated after a maximum of two treatments, 3–6 weeks apart. Before treatment, all patients had structural tendon changes and neo-vascularisation demonstrated with US and colour doppler. Under US and colour doppler-guidance, the injections targeted the area of neo-vascularisation just outside the ventral part of the tendon. For evaluation, the patients recorded the severity of Achilles tendon pain during tendon loading activity, before and after treatment, on a VAS. Patients satisfaction with treatment was also assessed. At follow-up (mean 3 months) after a maximum of two treatments, 5/10 patients in group A were satisfied with the treatment and had a significantly reduced level of tendon pain (p<0.005). In group B, no patient was satisfied with treatment. In the pain-free tendons, but not in the painful tendons, neo-vascularisation was absent after treatment. After completion of the study, treatment with Polidocanol injections (Cross-over in group B and additional treatments in group A) resulted in 10/10 and 9/10 satisfied patients in group A and B, respectively. In summary, injections with the sclerosing substance Polidocanol have the potential to reduce tendon pain during activity in patients with chronic painful mid-portion Achilles tendinopathy.     

PRP improves short term clinical results in tendinopathy of Achilles tendon

BackgroundChronic Achilles tendinopathy is a common pathology and standardized treatment strategies are lacking. The purpose of this study is to evaluate the efficacy of Platelet Rich Plasma (PRP) injections in treatment of Achilles tendinopathy.Materials and MethodsTwenty tendons in seventeen patients were included. Mean age of participants was 52.6 years (range, 34-72 years). All patients were treated by one single PRP injection. American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score and pain level according to Visual Analogue Scale (VAS) were noted in all patients pre-treatment and at 2 weeks, 2 and 6 months post-treatment.ResultsThe average AOFAS Hindfoot Score increased from 37.95 points (range, 33 to 52 points) pre-treatment to 90.8 (range, 83 to 97 points) post-treatment at 6 months. The average pain level according to VAS decreased from 8.65 points pre-treatment to 1.15 points post-treatment at 6 month. All patients returned to daily activities after 2 weeks and to sports activities after 1 month. Two of the patients were able to practice sports after the 3 month post PRP injection due to pain. None of the patients showed complications or adverse effects after the PRP injection.ConclusionLocal PRP injections showed effective results in chronic Achilles tendinopathy without any complications and seems to be a good treatment alternative in this entity. Moreover it might have the ability to avoid surgical intervention.Level of EvidenceIV.     

Effects of tendon viscoelasticity in Achilles tendinosis on explosive performance and clinical severity in athletes

The aim was to compare viscoelastic properties of Achilles tendons between legs in elite athletes with unilateral tendinosis, and to investigate relationships between the properties and explosive performance and clinical severity. Seventeen male athletes (mean ± standard deviation age, 27.3 ± 2.0 years) who had unilateral, chronic middle‐portion tendinopathy of the Achilles tendon were assessed by the Victorian Institute of Sport Assessment questionnaire, measurements of tendon viscoelastic properties, voluntary electromechanical delay (EMD), normalized rate of force development (RFD), and one‐leg hopping distance. Compared with the non‐injured leg, the tendinopathic leg showed reduced tendon stiffness (?19.2%. P < 0.001), greater mechanical hysteresis (+21.2%, P = 0.004), lower elastic energy storage and release (?14.2%, P = 0.002 and ?19.1%, P < 0.001), lower normalized RFD at one‐fourth (?16.3%, P = 0.02), 2/4 (?17.3%, P = 0.006), and three‐fourths maximal voluntary contraction (?13.7%, P = 0.02), longer soleus and medial gastrocnemius voluntary EMD (+26.9%, P = 0.009 and +24.0%, P = 0.004), and shorter hopping distances (?34.1%, P < 0.001). Tendon stiffness was correlated with normalized RFD, voluntary EMD in the medial gastrocnemius, and hopping distances (r ranged from ?0.35 to 0.64, P < 0.05). Hysteresis was correlated to the soleus voluntary EMD and hopping distances (r = 0.42 and ?0.39, P < 0.05). We concluded that altered tendon viscoelastic properties in Achilles tendinosis affect explosive performance in athletes.     

Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain

The purpose of this double-blind study was to evaluate the effects of iontophoresis with dexamethazone to iontophoresis with saline solution on patients who had acute (less than 3 months) pain from the Achilles tendon, in terms of range of motion, muscular endurance, pain and symptoms. Twenty-five patients (15 men and 10 women), aged between 18 and 76 years (mean=38), were evaluated before and after 2 weeks of treatment with iontophoresis, as well as after 6 weeks, 3 and 6 months and 1 year. Two groups were treated for 2 weeks with iontophoresis for each treatment. Three ml of dexamethazone were used for the experiment group (n=14) and 3 ml of saline solution for the control group (n=11). Both groups then followed the same rehabilitation programme for 10 weeks. Good reliability was found for the toe-raise and range of motion tests. Poor reliability was, however, found for the pain on palpation test, which was therefore excluded. No difference was found between or within groups for the toe-raise test. Several significant improvements were seen in the experiment group but not in the control group, in the range of motion test, pain during and after physical activity, pain during walking and walking up and down stairs, morning stiffness and tendon swelling. Even though the small sample size limits the possibilities to draw definite conclusions, we conclude from the present study, using a double-blind, randomised approach and a 1-year follow-up period, that positive effects from using iontophoresis with dexamethazone were found in the treatment of patients with acute Achilles tendon pain.     

In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain

This investigation was to our knowledge the first to use the microdialysis technique to study concentrations of substances in a human tendon. In four patients (mean age 40.7 years) with a painful nodule in the Achilles tendon (chronic Achilles tendinosis) and in five controls (mean age 37.2 years) with normal Achilles tendons (confirmed by ultrasonography) the local concentrations of glutamate and prostaglandin E₂ were measured under resting conditions. A standard microdialysis catheter was inserted into the Achilles tendon under local anesthesia. Sampling was performed every 15 min over a 4-h period. The results showed significantly higher concentrations of glutamate in tendons with tendinosis than in normal tendons (196 ± 59 vs. 48 ± 27 μmol/l, P < 0.05), and there were no significant changes in glutamate concentration over the period of investigation. There were no significant differences in the mean concentrations of prostaglandin E₂ (83 ± 22 vs. 54 ± 24 pg/ml) between tendons with tendinosis and normal tendons. In conclusion, in situ microdialysis appears a useful method to study certain metabolic events in tendon tissue. The higher concentrations of the excitatory neurotransmitter glutamate in Achilles tendons with a painful nodule may possibly be involved in the pain mechanism in this chronic condition. Furthermore, there were no signs of inflammation in the tendons with painful nodules, as indicated by the normal prostaglandin E₂ levels. Received: 30 March 1999 Accepted: 30 May 1999     

Endoscopic assisted flexor hallucis tendon transfer in the management of chronic rupture of Achilles tendon

Operative treatment is indicated in the management of chronic Achilles tendon rupture. Reconstruction of chronic Achilles tendon rupture can be classified into end-to-end repair, tendo Achilles advancement or flap reconstruction, local tendon transfer and implantation with autografts, allografts or synthetic materials. Following debridement of the tendon ends and with retraction of the proximal tendon fragment, a large gap will be present and direct tendon apposition with physiological tension is usually not possible. Flexor hallucis longus transfer is indicated if the tendon gap is more than 5 cm. We describe an endoscopic assisted flexor hallucis longus transfer in order to minimize the soft tissue dissection.     

A new surgical method to treat chronic ruptures and reruptures of the Achilles tendon

In patients with a chronic rupture or rerupture of the Achilles tendon, the recommended treatment is surgical. Various surgical techniques have been reported in the literature; however, the outcome is rarely evaluated with a sufficiently long follow-up, using appropriate end-points. The purpose of this study was to evaluate the subjective and objective outcome following a new surgical treatment for chronic rupture or rerupture of the Achilles tendon using augmentation with a free gastrocnemius aponeurosis flap. A total of 28 consecutive patients (22 male and 6 female) with a mean (SD) age of 46 (10.4) years were evaluated at a median (range) of 29 (12-117) months after surgery. The surgical technique involved making a single incision and then using a free gastrocnemius aponeurosis flap to cover the tendon gap after an end-to-end suture. The patients were evaluated using the Achilles tendon rupture score (ATRS) and a detailed questionnaire relating to symptoms, physical activity and satisfaction with treatment. The functional evaluation consisted of a validated test battery measuring different aspects of muscle/tendon function of the gastrocnemius/soleus and Achilles tendon complex. The median (range) ATRS was 83 (24-100). There were no reruptures. In terms of surgical complications, there was one deep infection, three wound closure complications and deep venous thrombosis in two patients. All but one patient returned to work within 6 months of surgery. Sixteen (57%) patients were satisfied with the treatment. There was a significant decrease in the level of physical activity after the injury compared with before the injury (p = 0.004). Of the 25 patients who participated in recreational sports prior to injury, 13 (52%) returned to the same activity level after treatment. In terms of jump performance, no significant differences were found between the healthy and injured sides. There was, however, a significant decrease in strength, in terms of both concentric and eccentric-concentric toe raises and the toe-raise test for endurance compared with the healthy side. The use of a free gastrocnemius aponeurosis flap to treat chronic ruptures and reruptures of the Achilles tendon rendered a good overall subjective and objective outcome in the majority of patients. The use of a single incision in combination with a free flap augmentation produced favourable results.     

Lesions of the Achilles tendon: Evaluation with ultrasonography and magnetic resonance imaging

Purpose

This work aims at evaluating the role of ultrasonography and magnetic resonance imaging in the diagnosis of the lesions affecting Achilles tendon of the ankle joint.

Patients and methods

The study is a prospective study of 28 patients. Some of them are complaining of a posterior heel pain, stiffness & a limitation of movements, soft tissue thickness and swollen and ecchymotic ankle. Plain X-ray (anteroposterior and lateral views), ultrasound examination were performed for both ankles of all patients with the patients in a prone position, the Achilles tendon was examined from its musculotendinous junction to its calcaneal insertion in both longitudinal and transverse views. Finally, MRI was performed with the patients in supine position, the foot is dorsiflexed, axial and sagittal T1, T2-weighted images, STIR & proton density were done for all patients.

Results

Out of 28 patients that were examined, the final diagnosis included; eight cases of tendinopathy (five cases peritendinosis, and three cases tendinosis), 16 cases of partial thickness tear (as compared to arthroscope), and four cases of full thickness tear.

Conclusion

Ultrasound is an important complementary diagnostic tool in the diagnosis of lesions of Achilles tendon, it is as good as MRI in the diagnosis of tendinopathy and full thickness tear, however MRI is more superior in the diagnosis of partial thickness tear, and in the differentiation of the different types of tendinopathy.     

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.     

Ossification of the Achilles tendon: imaging abnormalities in 12 patients

Ossification of the Achilles tendon is a rare clinical entity that is characterized by the presence of an ossific mass contained within the fibrocartilaginous substance of the tendon. Because the radiographic features of this condition have not been documented entirely and the magnetic resonance (MR) imaging findings have not been determined, a review of 16 affected tendons in 12 patients was performed in an attempt to characterize the imaging abnormalities associated with this process. MR imaging was performed in three Achilles tendons which demonstrated thickening of the tendons at the level of the ossifications and a lack of intratendinous signal abnormalities compatible with acute tendinitis. Signal intensity similar to that of bone marrow was present in the ossifications.     

切口内筋膜血管丛下结合锚钉治疗新鲜闭合性跟腱断裂方法的探讨

目的探讨切口内筋膜血管丛下结合铆钉治疗新鲜闭合性跟腱断裂方法的临床疗效。方法对48例闭合性跟腱断裂患者行跟腱内侧切口,术中显露胫后动脉穿支,游离并保护其筋膜血管丛,形成连接切口两端皮肤筋膜血管蒂桥,结合铆钉编织缝合;6周去除外固定后,进行伸展及等长收缩等训练。结果术后48例均获得随访,随访时间9个月~2年,平均12.92个月,术后按照美国足踝外科协会(American Orthopaedic FootAnkle Society,AOFAS)踝与后足功能评价功能评分标准,其中优40例,良5例,可3例,优良率为93.75%(45/48)。无一例发生腓肠神经及胫神经损伤、跖部痛性瘢痕、足底内外侧神经损伤、伤口感染、裂开。结论采用跟腱内旁切口,保护筋膜血管丛,结合铆钉修复跟腱断裂手术方法治疗新鲜闭合性跟腱断裂,手术操作简便,吻合方法可靠,创伤小,皮肤坏死率低,功能恢复佳,适用于基层医院开展。     

Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid injections in a clinical setting

In published efficacy studies on Achilles tendinopathy (AT) exercise alone results in improvement in 60–90% of the cases. However, this high success rate cannot be expected in usual clinical practice. We prospectively investigated the effectiveness of a treatment regimen consisting of home‐based exercises (concentric, eccentric, and stretching) and optional glucocorticosteroid (GCS) injections in patients with (AT) in a usual clinical setting. Patients unable to commence or progress in exercise were offered GCS, hypothesizing that the GCS would facilitate exercise. Ninety‐three consecutive patients with AT referred to two outpatient rheumatology clinics were registered, and seen at five visits over a 6‐month period. Exercises seemed to have a slow, but long‐lasting effect with GCS having a dramatic short‐term effect on symptoms. Twenty‐six percent of the patients could proceed with training alone, the remainder received one to three supplementary GCS. There were significant improvements on all outcome variables over time (P ≤ 0.001). At follow‐up, 42 had no more symptoms, 29 good result, 16 slightly improved, 4 unchanged, and 2 slightly worse. Overall, 94% of the patients had improved, and we thus recommend the use of GCS injections in AT patients if training alone does not lead to improvement.     

MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic individuals

Objective: To differentiate MR imaging characteristics of symptomatic as compared with asymptomatic Achilles tendons. Design: 1.5 T MR images of 94 feet (88 patients) with ”abnormal” MR examinations were retrospectively evaluated and clinically correlated. Two masked, independent observers systematically evaluated for intratendon T2 signal, tendon thickness, presence of peritendonitis, retrocalcaneal bursal fluid volume, pre-Achilles edema, bone marrow edema at the Achilles insertion, and tears (interstitial, partial, complete). These findings were correlated with symptoms (onset and duration) and physical examination results (tenderness, palpable defects, increased angle of resting dorsiflexion). Results: Of the 94 ankles, 64 ankles (32 females, 29 males) were clinically symptomatic. No relationship between Achilles tendon disorders and age or gender was identified. Asymptomatic Achilles tendons frequently demonstrated mild increased intratendon signal (21/30), 0.747 cm average tendon thickness, peritendonitis (11/30), pre-Achilles edema (12/30), and 0.104 ml average retrocalcaneal bursal fluid volume. Symptomatic patients had thicker tendons (0.877 cm), greater retrocalcaneal fluid volume (0.278 ml), more frequent tears (23/64), a similar frequency of peritendonitis (22/64) but less frequent pre-Achilles edema (18/64). Sixty-four percent of the Achilles tendon tears were interstitial. Except for two interstitial tears in control patients, the majority of Achilles tears were in symptomatic patients (14/16). Only symptomatic tendons demonstrated partial or complete tendon tears. In addition, calcaneal edema was found almost exclusively in actively symptomatic patients. Thicker tendons were associated more often with chronic symptoms and with tears. When present in symptomatic patients, peritendonitis was usually associated with acute symptoms. The presence of pre-Achilles edema, however, did not distinguish acute from chronic disorders. Conclusion: There is significant overlap of MR findings in symptomatic and asymptomatic Achilles tendons. Furthermore, there is apparently a spectrum of disease in symptomatic tendons ranging from subtle intratendinous and peritendinous signal to partial and complete tendon tear. Received: 17 March 2000 Revision requested: 26 May 2000 Revision received: 19 July 2000 Accepted: 19 July 2000