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.     

Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial

Background

Achilles tendinopathy is a common condition, which can become chronic and interfere with athletic performance. The proteinase inhibitor aprotinin (as injection) has been found to improve recovery in patellar tendinopathy¹ (evidence level 1b²) and Achilles tendinopathy.³ Internationally this therapy is being used based on this limited knowledge base.

Aim

To evaluate whether aprotinin injections decrease time to recovery in Achilles tendinopathy.

Method

A prospective, randomised, double blind, placebo controlled trial was performed comparing saline (0.9%) plus local anaesthetic injections and eccentric exercises with aprotinin (30 000 kIU) plus local anaesthetic injection and eccentric exercise. Three injections were given, each a week apart. In total, 26 patients, with 33 affected tendons, were enrolled for this study.

Results

At no follow up point (2, 4, 12, or 52 weeks) was there any statistically significant difference between the treatment group and placebo. This included VISA‐A scores⁴ and secondary outcome measures. However, a trend for improvement over placebo was noted.

Conclusion

In this study on Achilles tendinopathy, aprotinin was not shown to offer any statistically significant benefit over placebo. Larger multicentre trials are needed to evaluate the efficacy of aprotinin in Achilles tendinopathy.     

Efficacy of platelet-rich plasma injections in pain associated with chronic tendinopathy: A systematic review

Background: Chronic tendinopathy has often been a management dilemma for general practitioners. With our understanding of the pathophysiology of tendinopathy evolving, so has our management, with the advent of newer strategies such as topical glycerol trinitrate, extracorporeal shock-wave therapy, as well as platelet-rich plasma (PRP). Aim: To systematically review the literature regarding PRP therapy in chronic tendinopathy. Design and setting: The databases used in our search include the Elton B. Stephens Co. (EBSCO) database, Medline, the Cochrane library, Ovid, and Embase (the Excerpta Medica database). A total of 389 articles were reviewed from Feb 2010 to April 2014, for possible inclusion. Of these articles, a total of 9 randomized controlled trials (RCTs) met our inclusion criteria. Only 1 RCT was excluded due to previous surgery in both the trial and control groups. Methods: Each article was reviewed independently by 2 authors. Each article was analyzed using the Cochrane Criteria checklist. Where any discrepancy occurred in results, a third independent reviewer was consulted. Results: Our review found that PRP was most effective in patellar and lateral epicondylar tendinopathy, with both RCTs in the patellar section of our study supporting the use of PRP in pain reduction at 3 and 12 months, whereas 2 of 4 studies in the lateral epicondylar section showed improvements in pain and disability at 6 and 12 months. There was a lack of evidence to support the use of PRP in Achilles and rotator cuff tendinopathy. Conclusions: Although the results of this review show promise for the use of PRP in chronic tendinopathy, the analysis highlighted the need for more controlled clinical trials comparing PRP with placebo.     

Relationship between neovascularization and clinical severity in Achilles tendinopathy in 556 paired measurements

Neovascularization is frequently observed in tendinopathy. Previous studies have focused on the role of neovascularization in Achilles tendinopathy, but have been conducted in small series. It is still unclear whether the degree of neovascularization is related to severity of symptoms. The purpose was to study the relationship between ultrasonographic neovascularization and clinical severity in patients with Achilles tendinopathy. In this prospective cohort study, data on 127 patients (141 tendons) were assembled from databases of three clinical trials. All patients followed an eccentric exercise program. The Öhberg neovascularization score (0–4+) and Victorian Institute of Sports Assessment‐Achilles (VISA‐A) score (split into domains: pain, function and activity) were collected during baseline and follow‐up. The relationship between neovascularization and VISA‐A score was calculated. At baseline, 107 tendons (76%) showed some degree of neovascularization. In 556 coupled measurements, neovascularization was weakly related to the VISA‐A score [Exp (B) 1.017, 95% confidence interval (CI), 1.007–1.026]. No significant relationship was found between neovascularization and the pain domain (P = 0.277) and the activity domain (P = 0.283), but there was between neovascularization and the function domain of the VISA‐A score [Exp (B) = 1.067, 95% CI 1.018–1.119]. In conclusion, neovascularization in Achilles tendinopathy is weakly related to clinical severity, mainly based on the function domain of the VISA‐A score.     

The role of eccentric training in the management of Achilles tendinopathy: A pilot study

ObjectiveTo investigate the effect of different types of treatment on Achilles tendinopathy, one proposed to increase tensile strength of the tendon, the other a more traditional treatment used in a clinical setting.DesignRepeated measures trial comparing two interventions.SettingSports injury clinic.ParticipantsTwenty-five participants were randomly allocated to the eccentric group (n=13) or the control group (n=12).Main outcome measuresThe VISA-A questionnaire was used to determine outcomes and was administered to all participants at 0, 4, 8, and 12 weeks.ResultsAll subjects significantly improved over the 12-week period (p=0.0001), but the eccentric group demonstrated significantly higher (p=0.014) VISA-A scores at 12 weeks.ConclusionThe study suggests that the addition of a 12-week eccentric exercise programme to conventional treatment of ultrasound and deep transverse frictions is more effective in treating Achilles tendinopathy than conventional treatment alone.     

The clinical impact of platelet-rich plasma on tendinopathy compared to placebo or dry needling injections: A meta-analysis

ObjectiveThe purpose of this meta-analysis was to compare the impact of platelet-rich plasma with that of placebo or dry needling injections on tendinopathy.MethodsThe databases of PubMed, CENTRAL, Scopus, Web of Science, and trial registries, reference lists, and conference abstract books were searched up to December 2014. Adults with tendinopathy in randomized controlled trials were enrolled. The trials compared effect of platelet-rich plasma with that of placebo or dry needling. We used subgroup analysis linked to the anatomical location of the tendinopathy. The primary outcome was pain intensity at two or three and six months after intervention. The secondary outcome was functional disability at three months after treatment.ResultsFive trials were included. There was a statistically significant difference in favor of the platelet-rich plasma intervention at the second primary outcome time point (SMD −0.48, 95%CIs −0.86 to −0.10, I² = 0%, p = 0.01) and at the secondary outcome time point (SMD −0.47, 95%CIs −0.85 to −0.09, I² = 0%, p=0.01).ConclusionsPlatelet-rich plasma did not provide significantly greater clinical benefit versus placebo or dry needling for the treatment of tendinopathy at a six-month follow-up. However, there was a marginal clinical difference in favor of platelet-rich plasma injections on rotator cuff 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.     

Evaluation of lower leg function in patients with Achilles tendinopathy

Achilles tendinopathy is considered to be one of the most common overuse injuries in elite and recreational athletes. However, the effect that the Achilles tendinopathy has on patients’ physical performance is still unclear. The purpose of this study was to evaluate if Achilles tendinopathy caused functional deficits on the injured side compared with the non-injured side in patients. A test battery comprised of tests for different aspects of muscle-tendon function of the gastrocnemius, soleus and Achilles tendon complex was developed to evaluate lower leg function. The test battery’s test–retest reliability and sensitivity (the percent probability that the tests would demonstrate abnormal lower limb symmetry index in patients) were also evaluated. The test battery consisted of three jump tests, a counter movements jump (CMJ), a drop counter movement jump (drop CMJ) and hopping, and two strength tests, concentric toe-raises, eccentric–concentric toe-raises and toe-raises for endurance. The reliability was evaluated through a test–retest design on 15 healthy subjects. The test battery’s sensitivity and possible functional deficits in patients with Achilles tendinopathy were evaluated on 42 patients (19 women and 23 men). An excellent reliability was found between test days 1–2 and 2–3 for all tests (ICC = 0.76–0.94) except for concentric toe-raise, test 2–3, which had fair reliability (ICC = 0.73). The methodological error ranged from 8 to 17%. There were significant differences (P = 0.001–0.049) between the non-injured (or least symptomatic) side and injured (most symptomatic) side for hopping, drop CMJ, concentric and eccentric–concentric toe-raises, and significant differences (P = 0.000–0.012) in the level of pain during CMJ, hopping, and drop CMJ. The sensitivity of the test battery at a 90% capacity was 88. Achilles tendinopathy causes not only pain and symptoms in patients but also apparent impairments in various aspects of lower leg muscle-tendon function as measured with the test battery. This test battery is reliable and able to detect differences in lower leg function between the injured or “most symptomatic” and non-injured or “least symptomatic” side in patients with Achilles tendinopathy. The test battery has higher demand on patients’ function compared with each individual test.     

Applying physical science principles to mid‐substance Achilles tendinopathy and the relationship to eccentric lengthening exercises

Mid‐substance Achilles tendinopathy is common in the active population. Eccentric (lengthening) exercises are known to be effective in alleviating the clinical condition. To better understand mid‐substance Achilles tendinopathy and the response to lengthening exercises physical science principles of elasticity are applied. We apply elastic motion laws to the spring‐like tendon as well as the normal and pathological adaptation seen with this common injury. We will validate important assumptions of the spring‐like behavior of the tendon and then apply these findings to the injured and rehabilitating states. Our analysis considers that the tendon can be viewed as being spring‐like with elasticity principles being applicable and the force exerted on the tendon during lengthening is primarily in a uniaxial direction. This applied lengthening force results in tendon mechanical and structural adaptation. Injury, and ultimately the clinical condition, occurs when the applied force exceeds the ability of the tendon to normally adapt. Morphological changes of the injured tendon are an attempt by the body to make the tendon more compliant. Lengthening exercises can be assessed as achieving this task with an improvement of tendon compliance. Physical science analysis proposes that the preferred rehabilitation tendon pathway is to try and decrease tendon stiffness to allow for more tendon lengthening. The body's morphological alterations of the pathological tendon are also consistent with this approach. For mid‐substance Achilles tendinopathy, this adaptation of decreased stiffness ultimately increases the tendons ability to withstand applied force during lengthening.     

Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis

IntroductionBiomechanical alterations during running and hopping in people with Achilles tendinopathy (AT) may provide treatment and prevention targets. This review identifies and synthesises research evaluating biomechanical alterations among people with AT during running, jumping and hopping.MethodMEDLINE, EMBASE, CiNAHL and SPORTDiscus were searched in July 2018 for case control, cross-sectional and prospective studies investigating kinematics, kinetics, plantar pressures and neuromuscular activity in AT participants during running or hopping. Study quality was assessed with a modified version of the Downs and Black quality checklist, and evidence grading applied.Results16 studies reported 249 outcomes, of which 17% differed between groups. Reduced peroneus longus (standardized mean difference [95%CI]; −0.53 [−0.98, −0.09]) and medial gastrocnemius (−0.60 [−1.05, −0.15]) amplitude in AT runners versus control was found (limited evidence). Increased hip adduction impulse 1.62 [0.69, 2.54], hip peak external rotation moment (1.55 [0.63, 2.46] and hip external rotation impulse (1.45 [0.55, 2.35]) was found in AT runners versus control (limited evidence). Reduced anterior (−0.94 [−1.64, −0.24] and greater lateral (−0.92 [−1.61, −0.22]) displacement of plantar pressure preceded AT in runners (limited evidence). Delayed onsets of gluteus medius (1.95 [1.07, 2.83] and gluteus maximus (1.26 [0.48, 2.05] and shorter duration of gluteus maximus activation (−1.41 [−2.22, −0.61] was found during shod running in the AT group versus control (limited evidence). Earlier offset time of gluteus maximus (−1.03 [−1.79, −0.27] and shorter duration of activation of gluteus medius (−0.18 [−0.24, −0.12] during running in AT runners versus control was found (limited evidence). Reduced leg stiffness was found in the affected side during submaximal hopping (−0.39 [−0.79, −0.00]) (limited evidence).ConclusionThis review identified potential biomechanical treatment targets in people with AT. The efficacy of treatments targeting these biomechanics should be assessed.Systematic review registryPROSPERO registration number: CRD42016048636.     

Ultrasound guided injection in patellar tendinopathy; clinical outcomes of platelet-rich plasma compared to high-volume injection

Objectives

To assess the efficacy of ultrasound guided injection of platelet rich plasma versus high volume injection in treatment of patellar tendinopathy, in patients not responding to conservative treatment.

Additional evidence supports association of common genetic variants in MMP3 and TIMP2 with increased risk of chronic Achilles tendinopathy susceptibility

ObjectivesTo systematically evaluate the effects of matrix metalloproteinase-3 (MMP3) and tissue inhibitor of metalloproteinase-2 (TIMP2) on chronic Achilles tendinopathy (AT) susceptibility. Chronic AT is one of the most prevalent and severe injuries in athletes. Early studies suggested that tendon extracellular matrix (ECM) may be involved in the pathogenesis of chronic AT. MMP3 is an important member of the MMP family and is important to ECM integrity. In addition, tissue inhibitor of metalloproteinase-2 (TIMP2) can indirectly limit the activity of MMP3 activity.DesignCase-control genetic association study.MethodsA total of 1084 chronic AT patients and 2188 controls with Chinese Han ancestry were recruited. Twenty-one SNPs, 4 mapped to MMP3 and 17 mapped to TIMP2, were selected and genotyped. Genetic association analyses and eQTL analyses were performed. In addition, we also examined the potential effects of epistasis using a case-only study design.ResultsTwo SNPs, rs679620 (OR = 0.82, P = 0.0006, MMP3) and rs4789932 (OR = 1.2, P = 0.0002, TIMP2) were identified to be significantly associated with chronic AT risk. No significant results were obtained from epistasis analyses. SNP rs4789932 was identified to be strongly associated with the gene expression level of TIMP2 in two types of human tissues: atrial appendage (P = 0.0003) and tibial artery (P = 0.0009).ConclusionsWe have identified genetic polymorphisms in MMP3 and TIMP2 to be significantly associated with chronic AT risk. Further eQTL analyses indicated that SNP rs4789932 of TIMP2 was related to the gene expression levels of TIMP2. These results suggest important roles for MMP3 and TIMP2 in the pathophysiology of chronic AT.     

Non-surgical treatment of patellar tendinopathy: A systematic review of randomized controlled trials

Study designSystematic review of randomized controlled trials.ObjectivesTo determine the most effective non-surgical treatment interventions for reducing pain and improving function for patients with patellar tendinopathy.MethodsStudies considered for this systematic review were from peer-reviewed journals published between January 2012 and September 2017. All included studies used a visual analogue scale (VAS) to evaluate the participant’s pain. The majority of the included studies also used the Victorian Institute of Sport Assessment Patellar Tendinopathy (VISA-P questionnaire) to assess participant’s symptoms and function.ResultsNine randomized controlled trials fit the inclusion criteria and were analyzed. The results of three studies supported the use of isometric exercise to reduce pain immediately. One study found patellar strapping and sports taping to be effective for reduction in pain during sport and immediately after. Eccentric exercise, Dry Needling (DN) (2 studies), injections with Platelet Rich Plasma (PRP), Autologous Blood Injection (ABI), and saline were found to have a more sustained effect on reducing pain and improving knee function.ConclusionIsometric exercise, patellar strapping, sports taping, eccentric exercise, injections with PRP, ABI, and saline and DN demonstrated a short-term pain relieving and functional improvement effect in subjects with patellar tendinopathy. Longer term follow up on interventions involving eccentric exercise, DN, and injections with PRP, ABI and saline showed sustained pain reduction and improvement in knee function.Level of evidenceLevel 1.     

Efficacy of a platelet-rich plasma injection for the treatment of proximal hamstring tendinopathy: A pilot study

Objectives

To determine the efficacy of an ultrasound-guided platelet-rich plasma (PRP) injection in the treatment of patients with proximal hamstring tendinopathy (PHT).

The twisted structure of the human Achilles tendon

The Achilles tendon (AT) consists of fascicles that originate from the medial head of the gastrocnemius (MG), lateral head of the gastrocnemius (LG), and soleus muscle (Sol). These fascicles are reported to have a twisted structure. However, there is no consensus as to the degree of torsion. The purpose of this study was to investigate the twisted structure of the AT at the level of fascicles that originate from the MG, LG, and Sol, and elucidate the morphological characteristics. Gross anatomical study of 60 Japanese cadavers (111 legs) was used. The AT fascicles originated from the MG, LG, and Sol were fused while twisting among themselves. There were three classification types depending on the degree of torsion. Further fine separation of each fascicle revealed MG ran fairly parallel in all types, whereas LG and Sol, particularly of the extreme type, were inserted onto the calcaneal tuberosity with strong torsion. In addition, the sites of Sol torsion were 3–5 cm proximal to the calcaneal insertion of the AT. These findings provide promising basic data to elucidate the functional role of the twisted structure and mechanisms for the occurrence of AT injury and other conditions.     

Characterisation of Achilles tendon pain in recreational runners using multidimensional pain scales

ObjectivesThe main assessment tool for Achilles tendinopathy (AT) is the VISA-A. However, the VISA-A only assesses the physical impairments that result from tendon pain. This study sought to describe and assess tendon pain using other multidimensional pain scales; the short forms of the McGill pain questionnaire (sf-MPQ) and the Brief Pain Inventory (sf-BPI).DesignCross sectional observational study.Methods124 recreational runners with clinically confirmed mid-portion Achilles tendinopathy for at least 3 months were recruited from Cape Town, South Africa. They described and rated their tendinopathy symptoms by completing the VISA-A, sf-BPI and sf-MPQ questionnaires.ResultsTendon pain was largely described as a sensory type of pain with minimal affective elements. Sixty percent described their pain as aching. Significant proportions described it as tender (52.9%), throbbing (33.9%), hot burning (24.8%) and 33.8% ranked it as discomfiting or worse on the pain intensity score of the sf-MPQ. Tendon pain interfered with mood in 50.8% of the participants as well as with walking ability (72.5%), sleep (34.8%) and enjoyment of life (54.2%).ConclusionsTendon pain was described using a variety of adjectives which may suggest that AT has clinical subtypes. Tendon pain interferes with more than just physical function. Therefore, the recommendation is to conduct further studies using various pain questionnaires to elicit more details and better understand the nature of Achilles tendon pain.     

Self-reported pain with single leg heel raise or single leg hop offer distinct information as measures of severity in men with midportion and insertional Achilles tendinopathy: An observational cross-sectional study

ObjectivesTo investigate if self-reported pain with single leg heel raise (SLHR) or single leg hop (SLH) are concurrently valid to assess midportion (MPAT) or insertional Achilles tendinopathy (IAT) symptom severity, compared to the VISA-A. Additionally, if SLHR or SLH pain accounts for VISA-A variability, and if they are associated with psychological factors.Participants60 men with MPAT, 26 men with IAT.Main outcomesParticipants rated SLHR and SLH pain on a numerical rating scale (0 = none, 10 = worst). We investigated relationships between loading task pain, VISA-A, VISA-A constructs, and psychological outcomes (Pearson’s correlation coefficients). Linear regression determined best model accounting for VISA-A variability.ResultsIn MPAT, load tests shared fair-negative relationship with VISA-A, and VISA-A function. In IAT, SLHR had moderately strong-negative relationship with VISA-A, and pain and function constructs, and SLH shared fair-negative relationship with VISA-A, and pain and function constructs. Relationships were negligible between load tests and VISA-A activity in both conditions, and VISA-A pain in MPAT. In IAT, there was fair-positive relationship between pain catastrophising and load tests. Remaining psychological outcome relationships were negligible. Best model accounting for VISA-A included SLH in MPAT, and SLHR in IAT.ConclusionsDespite VISA-A and selected VISA-A construct associations, self-reported SLHR and SLH pain appears to provide distinct information.     

Cross-cultural adaptation and measurement properties of the VISA-A questionnaire for Chinese patients with Achilles Tendinopathy

ObjectiveTo culturally adapt the VISA-A into a simplified Chinese version (VISA-A-CHN) and test its measurement properties.DesignMethodological study;SettingHospital and university laboratory.Participants240 subjects were divided into the healthy (n = 80), at-risk (n = 80), and tendinopathy groups (n = 80).Main outcomes measuresThe internal consistency, test-retest reliability, construct validity, and the floor and ceiling effect of the VISA-A-CHN.ResultsThe VISA-A-CHN showed adequate internal consistency (Cronbach's α = 0.73, 95% CI 0.63 to 0.81), excellent test-retest reliability (ICC_3A,1 = 0.97, 95%CI = 0.95 to 0.98), standard error of measurement of 2.2 points, minimum detectable change of 6.0 points, with no floor and ceiling effects. Two factors (pain/symptoms and physical function/activity) were extracted in exploratory factor analysis. There were moderate associations of VISA-A-CHN score with scores of Lower Extremity Functional Scale and SF-36 physical components (r_s = 0.53–0.74, P < 0.01) but low associations with SF-36 mental components (r_s = 0.12–0.22, P > 0.05). VISA-A-CHN mean score of Achilles tendinopathy group was significantly lower than those of healthy and at-risk groups (P < 0.01).ConclusionsThe VISA-A-CHN is equivalent to the original version in terms of language and measurement properties. It can be used as the outcome measure for Chinese patients with Achilles tendinopathy.     

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.